Post on 05-Aug-2020
Appropriateness of Care: Better Care Made Easier
Appropriateness of Care Framework
A
Version 1: December 4, 2015
Appropriateness of Care Framework i Version 1: December 4, 2015
Executive Summary
A Framework for Improving
Appropriateness of Care in
Saskatchewan
The Canadian Medical Association (CMA) has defined Appropriateness of Care as:
“The right care provided by the right providers, to the right patient, in the right place, at
the right time, resulting in optimal quality care.” This definition has been adopted as the
vision statement for the Saskatchewan Appropriateness of Care program, with approval
from the CMA.
Saskatchewan’s health system leaders identified improving Appropriateness of Care as
one of the key system priorities in 2013-14 by indicating that a provincial framework
would be developed, with the intent that the framework will be broadly applied and
widely used by clinicians and health care organizations across the continuum of care. Two
ambitious targets have been set:
By March 31, 2018, 80% of clinicians in at least three selected clinical areas within two
or more service lines will be using agreed-upon best practices.
By March 31, 2018, at least three clinical areas have been deployed care standards and
used measurement and feedback to inform improvement at the provincial level.
When patients visit health care practitioners they assume and expect that the care they
receive is the best care for their condition. Patients and their families want care that is
evidence-informed and clarifies the best approach for treatment options.1 Physicians want
to provide the best care possible for their patients. An appropriate health care service is
defined as one for which the “the expected health benefit (increased life expectancy, relief
of pain, reduction in anxiety, improved functional capacity) exceeds the expected negative
1 From Innovation to Action: The First Report of the Health Care Innovation Working Group
Council of Federation; 2012
Appropriateness of Care Framework ii Version 1: December 4, 2015
consequences (mortality, morbidity, anxiety, pain, time lost from work) by a sufficiently
wide enough margin that the medication, treatment or procedure is worth doing.2
However, at times patients don’t always receive the best treatment options. for a variety of
reasons, including availability of services, access to care, variation in clinician practices
and lack of solid evidence available for clinicians to support best treatment options leading
to uncertainty and variation in decision-making. All these factors impact the
Appropriateness of Care that patients, clients and residents receive.
Inaccurate research, hasty recommendations, personal bias, lack of currency in education
or training, an abundance of information on the internet, and television talk shows
promoting the latest fad in health care (often without the rigor of evidence to support the
fad) all contribute to overuse, underuse, misuse and variation in health care, or,
inappropriate care. Unnecessary or wrong tests, treatments and procedures do not add
value and take away from care by potentially exposing patients to harm, and at times, lead
to more testing to investigate false positives, adding stress for patients. Additionally, this
wastes precious resources within an already stretched health care system, and contributes
to increased wait times for patients who really do require the tests and procedures.
Quality improvement initiatives in health care have made significant progress over the
past several decades; however, there are still significant areas of opportunity to address
Appropriateness of Care. The purpose of the provincial Appropriateness of Care
framework is to provide a shared understanding of what Appropriateness of Care means
to patients, clinicians, health system stakeholders and the public, and a strategy for the
health system to improve and embed Appropriateness of Care within a broad range of
patient-centered clinical areas. The framework has been developed based on research on
the successes of similar initiatives in several high-performing US-based health care
organizations, and aligns strongly with the Canadian Medical Association’s Choosing
Wisely Canada campaign.
Choosing Wisely Canada, launched in 2014, is a campaign to help physicians and patients
engage in conversations about unnecessary tests, treatments and procedures.3
“For many years, both physicians and patients have had a ‘more is better’ attitude. It is
time to adopt a ‘think twice’ attitude to avoid unnecessary and potentially harmful tests,
procedures and treatments.” Dr. Wendy Levinson, Choosing Wisely Canada
2 Appropriateness Criteria to Assess Variations in Surgical Procedure Use in the U.S. Elise Larson, Clifford Ko et al
JAMA Surgery. December 2011 3 Choosing Wisely Canada. Canadian Medical Association. Choosingwiselycanada.org
Appropriateness of Care Framework iii Version 1: December 4, 2015
Numerous health care initiatives have been successfully implemented in Saskatchewan,
and many more are currently underway. Most of these initiatives fit under the umbrella of
Appropriateness of Care and have been implemented without the benefit of using a
standard quality improvement methodology. A provincial framework will provide the
advantage of offering a standardized approach, supporting a more coordinated provincial
effort.
The Appropriateness of Care Framework is depicted in the schematic on page 18, and
includes the following components:
a quality improvement methodology to improve Appropriateness of Care at the clinical
practice level and the system structures required to embed Appropriateness of Care
into Saskatchewan health care organizations;
a stakeholder engagement and communication plan;
a plan that outlines infrastructure requirements for capturing, analyzing and reporting
essential data; and
a toolkit with information to support groups or organizations who want to undertake
improvement work in any clinical area.
In 2015-16 the Appropriateness of Care Framework is being tested in the clinical area of
Magnetic Resonance Imaging (MRI) of the lumbar spine where there is strong evidence
that suggests overuse of this diagnostic imaging modality in Canada.
Successful implementation of the framework requires a multi-year strategy and ongoing,
unwavering system-wide support for this transformational change. Organizations that the
framework is modeled after have taken many years to reach a stage of maturity in their
programs. To be successful, a health care system that ”thinks and acts as one,” working
towards common understanding and agreed-upon evidence-based practices, will have a
key role to play in recognizing when health care decisions result in “too much or too little”
care being provided. There is a role for clinicians, patients, families and the public to work
together to improve Appropriateness of Care. In Saskatchewan these roles will be
supported by the provincial Appropriateness of Care Framework.
With the system-wide adoption of the Saskatchewan Healthcare Management System and
advancement of Patient and Family-Centred Care over the last few years, the
Saskatchewan health system is poised to start down the path of improving
Appropriateness of Care, another major transformative initiative that will help the system
achieve its goals of: Better Health, Better Care, Better Value and Better Teams.
Appropriateness of Care Framework iv Version 1: December 4, 2015
Table of Contents
Executive Summary ............................................................................................................................................. i
Introduction ....................................................................................................................................................... 1
Appropriateness of Care Vision, Outcome Target and Improvement Target .................................................... 3
Key Values and Guiding Principles ..................................................................................................................... 4
What is Appropriateness of Care? ..................................................................................................................... 4
Underlying Causes of Inappropriate Care .......................................................................................................... 6
Saskatchewan Context ....................................................................................................................................... 8
Moving Forward with Appropriateness of Care in Saskatchewan ..................................................................... 9
1. System-wide adoption of a common methodology for improving Appropriateness of Care ............ 10
2. Provincial, Regional and Organizational Structures for Appropriateness of Care ............................... 10
3. System-Wide Support Structure for Appropriateness of Care ............................................................ 13
a) An Involvement Strategy.................................................................................................................. 14
b) A Robust Clinical Information System .............................................................................................. 15
c) Education and Training Programs .................................................................................................... 16
Next Steps ........................................................................................................................................................ 17
References ....................................................................................................................................................... 19
Appendix A: Opportunities to Align Appropriateness of Care with Provincial Initiatives ............................... 21
Appendix B: Physician Involvement Strategy .................................................................................................. 22
1. Introduction ......................................................................................................................................... 23
2. Guiding Principles ................................................................................................................................ 25
3. Key Drivers and Actions ....................................................................................................................... 27
4. Lessons Learned to Date ...................................................................................................................... 31
5. Using Physicians to Influence Change .................................................................................................. 32
References ................................................................................................................................................... 34
Appendix C: Stakeholder Involvement Strategy: Patients, Families, Public and Health System ..................... 35
1. Introduction ......................................................................................................................................... 36
2. Strategic Considerations ...................................................................................................................... 36
3. Key Messages to Communicate with Stakeholders about Appropriateness of Care .......................... 36
4. Involving Health System Leadership and Providers ............................................................................. 37
5. Involving Patients, Families and the Public .......................................................................................... 40
Appropriateness of Care Framework v Version 1: December 4, 2015
6. Feedback Loop and Evaluation ............................................................................................................ 45
7. Multi-year Action Plan ......................................................................................................................... 45
References: .................................................................................................................................................. 48
Appendix D: Data and Measurement Strategy .............................................................................................. 49
1. Introduction ......................................................................................................................................... 50
2. Drivers of Strong Data Systems ............................................................................................................ 50
3. Key Messages Regarding Appropriateness of Care and Data Strategy ................................................ 55
Appendix E: Provincial Appropriateness of Care Program Governance Structure .......................................... 57
Appendix F: Appropriateness of Care Framework Toolkit ............................................................................... 61
Appendix F: Appropriateness of Care Toolkit - Tool # 1 .................................................................................. 62
Implementation Process for Appropriateness of Care Methodology ......................................................... 62
Appendix F: Appropriateness of Care Toolkit - Tool #2 ................................................................................... 64
Process and Criteria for Selecting Appropriateness of Care Projects .......................................................... 64
Appendix F: Appropriateness of Care Toolkit - Tool #3 ................................................................................... 67
Shared Decision-Making: Involving Patients and Families in Treatment Decisions .................................... 67
Appendix F: Appropriateness of Care Toolkit - Tool #4 ................................................................................... 75
Data Development and Measurements for Appropriateness of Care Projects: Data Collection, Analysis
and Reporting .............................................................................................................................................. 75
Appendix F: Appropriateness of Care Toolkit - Tool #5 ................................................................................... 83
Saskatchewan Administrative Databases .................................................................................................... 83
Appendix F: Appropriateness of Care Toolkit - Tool #6 ................................................................................... 92
Important Documents Regarding Data ........................................................................................................ 92
Appendix F: Appropriateness of Care Toolkit - Tool #7 ................................................................................... 94
Surgical Variation and Appropriateness Working Group (Vascular Working Group) .................................. 94
Appropriateness of Care Framework 1 Version 1: December 4, 2015
Introduction
“For so many years the patient voice has been missing in
healthcare, contributing to varying outcomes for patients. By
incorporating the voice of the patient throughout many areas of
this work, [Appropriateness of Care] will ensure the goals of the
initiative will be met. [The Appropriateness of Care Vision] Right
care provided by the right provider, to the right patient, in the right
place, at the right time, resulting in optimal quality care … So
promising to our patients and families but also will make sure our
patients will be getting the safest quality of care.”
- Heather Thiessen, a Patient and Family Advisor
Appropriateness of Care has been noted in the literature for decades, mainly discussed as
variation in clinical practice across the entire continuum of care: from chronic disease
management to the use of medications, to surgery. As early as 1938 a study was published
documenting varying rates of tonsillectomies across geographical regions of England4,
noting geographic clusters of variation in how physicians treat patients with similar
conditions.
Appropriateness of Care in Saskatchewan was raised in Commissioner Tony Dagnone’s
Patient First Review, For Patients’ Sake, released in October 20095. According to the report,
patients with similar health conditions frequently experience differences in diagnostic
testing and treatment options, resulting in varied experiences and outcomes.
It’s accepted in health care that some variation in patient care is to be expected. There are
known geographic differences in population health status, including the genetic
predisposition to disease, socio‐economic status, lifestyle, nutrition, and other factors
which influence different patterns of health care. These examples are considered “justified
or warranted variation.” Decisions regarding treatment of medical conditions are
influenced by clinician education and training, available resources and capacity, as well as
individual and local practice cultures. These factors may lead to unjustified variation in
clinical care. Quality improvement experts contend that if unjustified or unwarranted
variation exists, there may be a potential quality of care issue. For example, in two similar
populations that do not differ in age, sex, health status, and other relevant determinants of
4 Variations in Hospital Admissions and the Appropriateness of Care: American Preoccupations?
John P. Bunker BMJ September 1990 5 For Patient’s Sake Patient First Commissioner’s Report for SK Minister of Health. Commissioner Tony Dagnone
October, 2009
Appropriateness of Care Framework 2 Version 1: December 4, 2015
need, if there are three times as many procedures, tests, medications administered in one
place compared to the other, both cannot be best practice – either there are too few
procedures in one population, too many in the other, or neither is getting it right. This
variation is now known to be a feature of almost every country’s health care, including
Canada, and this has potential for negative patient outcomes as well as unnecessary costs
to the health care system6.
As a result, there has been a growing interest in addressing Appropriateness of Care issues
in Canada:
In response to fiscal challenges, Ontario passed legislation in 2010 to strengthen the
commitment toward the delivery of high-quality care, the Excellent Care for All Act
(ECFAA) 2010. The ECFAA is a key component of a broad strategy that improves
the quality and value of patients’ experiences by providing them with the right
evidence-informed health care at the right time and in the right place.
In July 2013 the Council of the Federation (Provincial and Territorial Premiers)
recommended that all participating provinces and territories adopt guidelines as
appropriate for their jurisdiction for the use of medical imaging in minor head
injuries, lower back pain and headaches.
The Canadian Medical Association (CMA) launched Choosing Wisely Canada
campaign in April 2014 to raise awareness of inappropriate care contributed by
unnecessary tests, treatments and procedures. This campaign has been endorsed by
provincial and territorial medical associations, including the Saskatchewan Medical
Association (SMA).
Improving Appropriateness of Care is not new to the Saskatchewan health system. Since
2009 various clinical pathways for patients faced with prostate cancer, lower back pain,
joint pain in hips and knees and pelvic floor conditions have been developed and
implemented to improve the consistency of assessment and care and to use
multidisciplinary teamwork to provide the necessary information for patients to help
determine appropriate care options. In 2012, Saskatchewan Surgical Initiative’s Variation
and Appropriateness Working Group (VAWG) was formed to study surgical variation in
Saskatchewan and develop strategies to narrow the gap in rates of specific surgeries
performed. Currently, there are many other efforts to improve Appropriateness of Care
under various initiatives (Saskatchewan Context, page 8).
In 2014-15, the Saskatchewan health system Provincial Leadership Team (PLT) made a
commitment to improve Appropriateness of Care by making it one of the key priorities for
6 Population‐Based Variation in Rates of Surgical Interventions in Saskatchewan: A First Look at Province‐Wide
Data SK Surgical Variation and Appropriateness Working Group 2012
Appropriateness of Care Framework 3 Version 1: December 4, 2015
the health care system. An Appropriateness of Care team led by two physicians and an
administrative program lead, supported by the Ministry of Health and the Saskatchewan
Health Quality Council (HQC) was established to develop a provincial Appropriateness of
Care framework to be implemented across the system. The main purpose of the
framework is to provide a shared understanding of what Appropriateness of Care means
to patients, clinicians, health system stakeholders and the public, and a shared vision for
improving Appropriateness of Care in Saskatchewan by embedding it in daily work of
clinicians using a standard quality improvement approach that applies to a broad range of
patient-centred clinical areas.
Appropriateness of Care Vision, Outcome Target and Improvement Target
All patients and residents in Saskatchewan receive “Right Care, provided by the Right Providers, in the Right Place, at the Right Time, resulting in Optimal Quality of Care”
(adopted from the CMA)
By March 31, 2018, 80% of clinicians in three selected clinical areas within two or more service lines will be utilizing agreed upon best practices
At least three clinical area have deployed care standards and used measurement and feedback to inform improvement at the provincial level.
Vision Outcome Target Improvement Target
As previously mentioned, reaching the point where the Appropriateness of Care program
vision statement becomes a reality will depend on implementation of a multi-year strategy
and ongoing system-wide support for this transformational change. A system that is
working towards common understanding and agreed-upon evidence-based practices will
have a key role to play in recognizing when health care decisions result in “too much or
too little” care being provided.
Appropriateness of Care Framework 4 Version 1: December 4, 2015
Key Values and Guiding Principles
What is Appropriateness of Care?
In general, appropriate health care has been described as a treatment, procedure,
medication or intervention that is expected to do more good than harm for a patient with a
given health problem or set of problems, based on scientific evidence. The potential
benefit and risk associated with any intervention/procedure varies according to the
circumstances in which it is applied. In some cases the risks and benefits of an
intervention for a particular patient will be quite predictable; in others there is a higher
degree of uncertainty.
Optimizing health care delivery means reducing uncertainty – the more accurately we can
assess risk and potential benefit, the greater the likelihood of both improving outcomes
and avoiding harms. Where the risk outweighs the likely benefit, or the likely benefit is
very small, the intervention may be inappropriate. It is also inappropriate to withhold an
intervention where the likely benefits are considerable and the level of risk acceptable.
There are multiple perspectives that need to be considered in determining the value
(benefit vs harm) of a service, including those of the patient, the health care provider and
the health care system.
Key Guiding Principles
Clinician-Led
Evidence-Based Care
Effective Care
Patient- and Family-Centred Care
Information Sharing
Equitable Care
Standardized Care (does not
mean “exactly the same care
rather consistent care)
Continuous Learning and
Improvement
Interdisciplinary team (care
team)
Value to Clinicians, Patients and the System Eliminate unnecessary referrals, testing and
treatments, thereby reducing wasted time for
both clinicians and patients
Improve transparency in clinical decision-
making
Greater involvement and collaboration of
clinicians in developing new knowledge
Standardized care makes it easier for clinicians to
provide the care that meets the needs of patients
Reduced wait times by ensuring only the right
(best) tests or treatments are provided to patients
Reduce potential risks of patient harm associated
with unnecessary testing and treatments
Appropriateness of Care Framework 5 Version 1: December 4, 2015
Overuse, underuse, misuse and unjustified variation have been widely used to describe
care that may be considered “inappropriate.” 7
Overuse: Any patient who receives a treatment, procedure or medication for an
uncertain indication, which means that there is minimal or no scientific evidence
supporting that the benefits outweigh the risks. Patients may receive services that
are considered unnecessary (i.e. unnecessary tests), which may even endanger their
health if needless testing leads to more invasive procedures (i.e. medical imaging
tests leading to unnecessary exposure to radiation or surgical procedures that do
not improve patient outcomes). Unnecessary testing and screening can lead to false
positive diagnoses and overtreatment.
Underuse: Any patient who does not receive a treatment, procedure or medication
that is proven value to their condition based on evidence (i.e. effective care).
Underuse of effective care can result in a wasted opportunity to prevent serious
illness. For example, underuse of specific types of medications in cardiac-related
illnesses such as beta-blockers after an acute myocardial infarction and
inappropriate use of calcium-channel blockers have been associated with increased
rates of re-hospitalization, death, or both.
Misuse: Any patient who receives the wrong treatment, procedure or medication
during the course of their treatment (i.e. use of antibiotics in illnesses caused by
viruses; prescribing of specific medications in the elderly without a diagnosis,
duplicate medical imaging testing, such as CT when MRI is the most appropriate
test).
Unjustified Variation: Practice variation occurs among clinicians, hospitals, health
care organizations, regions, and health care systems and may be due to patient’s
clinical differences, population health differences, and geographical differences,
which are considered justifiable variation. Unjustified variation, however, may
indicate that there is an issue with inappropriate care (i.e. overuse, underuse and/or
misuse).
7 For Patient’s Sake Patient First Commissioner’s Report for SK Minister of Health. Commissioner Tony Dagnone
October, 2009
Appropriateness of Care Framework 6 Version 1: December 4, 2015
Underlying Causes of Inappropriate Care
“15% – 20% of care is ‘clinically inappropriate.”
- Dr. Brent James, Chief Quality Officer at Intermountain Healthcare in Utah
There is significant clinical variation in patient care happening across Canada. Several
reports issued by the Canadian Institute of Health Information8 (CIHI) over the past
several years provide examples of clinical variation in Canada which may indicate
inappropriate care.
Between 2007-08 and 2009-10, Newfoundland and Labrador had the highest
mastectomy rate (69%) in Canada, followed by Saskatchewan (65%). Quebec had
the lowest mastectomy rate (26%).
Saskatchewan had the highest rate in angioplasty with stents (PCI) and coronary
artery bypass surgery (CABG) despite the evidence that PCI and CABG do not
prevent heart attacks or improve survival rate for patients with stable angina
compared to medical therapy alone.
Alberta had the highest overall child birth assisted-delivery rate (e.g. vacuum-
assisted delivery and forceps-assisted) (16.8%) among the provinces, followed by
Saskatchewan (15.8%).
The primary Caesarian-section rate also varies significantly across Canada.
Newfoundland and Labrador and B.C. have the highest primary C-section rates
(23.5% and 22.9%, respectively), while Saskatchewan and Manitoba have the lowest
rates (14.7% and 14.4%, respectively).
According to the Saskatchewan Surgical Initiative’s Variation and Appropriateness
Working Group (VAWG) report released in July 2012, there is a significant range in rates
of certain high volume surgical procedures performed in Saskatchewan based on patient’s
geographical location, with a high-to-low variance range in some instances as high as 7 to
1. This data indicates that there may be Appropriateness of Care issues within specific
surgical procedures in the Saskatchewan health system.
Some of the factors that may contribute to overuse, underuse, misuse, and variation in
patient care include:
Access to patient information
eHealth Saskatchewan is building the platform for a universal electronic health
record for patients; however, patient information currently is fragmented and most
often information is located in several different charts in different physical
8 CIHI Health Indicator Reports; 2011, 2012; Breast Cancer Surgery in Canada, 2007-08 to 2009-10
Appropriateness of Care Framework 7 Version 1: December 4, 2015
locations. Obtaining clinical information (tests, test results and procedures
performed on patients) is challenging and time consuming, and leads to over-
testing in many instances.
Utilization of clinical practice guidelines (CPGs) among clinicians9
CPGs are “statements that include recommendations, intended to optimize patient
care, that are informed by a systematic review of evidence and an assessment of the
benefits and harms of alternative care options.” 10 They include criteria for helping
to determine appropriateness of care. Although many clinicians agree that they are
helpful sources of advice, good educational tools and likely to improve quality of
care, they also view them impractical and too rigid to apply to individual patients.
Critics indicate they may reduce clinician autonomy, oversimplify medicine
(standardizing practice around the average patient) and focus on cost-cutting,
limiting innovation and clinical freedom.11 CPGs often are not presented in a clearly
understandable or decipherable form. CPGs often aren’t integrated into clinicians’
work environments, making it difficult for clinicians to apply it to their daily
practice. Failure to make them available at the point of care rather than relying on
the ability of clinicians to read, remember and apply the guidelines contributes to
lower utilization. Engaging clinicians in developing and use CPGs or agreed-upon
best practices and then embedding them into their workflow or daily practice will
be key for improving utilization of CPGs. The preferred format needs to be
available “just in time,” where and when needed.
Limited patient involvement in health care decision-making
Patients are not always fully informed and involved in health care decision-making,
particularly when there is more than one treatment option available and minimal
evidence suggesting one option is better than the other. In this case, patient
involvement in treatment decision-making can be very important to achieve the
best possible outcomes for patients. Research shows that patients choose differently
when they are fully informed about treatment options with their benefits and
risks12. One of the Appropriateness of Care strategies is to inform patients about
their treatment options with benefits and risks, as well as involve them in the
treatment decision-making through embedding Shared Decision-Making (SDM)
9 Hidden Barriers to the Improvement of Quality of Care. Barbara J. McNeil. NEJM November, 2001
10 Institute of Medicine definition
11 Clinicians’ Attitudes to Clinical Practice Guidelines: A Systematic Review. Cynthia Farquhar et al. The Medical Journal
of Australia. August 2002. 12
Decision Aids for People facing Health Treatment or Screening Decisions. Stacey D, Bennett LC, Barry JM, Col FN, Eden BK, Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Légaré F and Thomson R. Cochrane Database of Systematic Reviews. 2011. Issue 10.
Appropriateness of Care Framework 8 Version 1: December 4, 2015
tools into the Appropriateness of Care projects (see the Patient/Families/Public
Stakeholder Engagement and Communication Plan).
Increased demand for particular treatments and diagnostic tests due to advanced
technologies and their availability
The abundance and availability of health care information has the potential to be
confusing and misleading for the public. Information available about medications,
treatments and procedures often is highly profiled on a variety of media sites, TV
shows, or social media, but may not be supported by rigorous research or evidence
or provide enough information for the general public to make an informed decision.
Saskatchewan Context
“I don’t blame anybody – they’re just doing what makes sense and we have to change what
makes sense.”
- Don Berwick, Former President/CEO of the Institute of Health Improvement
There are numerous opportunities to improve Appropriateness of Care within the
Saskatchewan health system. (See Appendix A: Opportunities for Appropriateness of Care
Framework to Align with Provincial Initiatives). A few examples where improvements are
required or work is underway include:
overuse or test substitution in medical imaging (MRI, CT);
overuse of specific laboratory tests (Vitamin D);
unnecessary referrals to specialists resulting in long wait times to see a specialist;
high volumes of patients, including seniors, receiving care in hospitals where
alternate care could be provided but not available elsewhere;
overuse of specific classes of medications in seniors;
overuse and misuse of antibiotics; and
underuse of effective treatments for patients with chronic diseases.
Many initiatives are underway to address some of these issues e.g. ED Waits and Patient
Flow, Chronic Disease Management-Quality Improvement Program, Seniors’ House Calls,
Home First/Quick Response Home Care, Improving Access to Specialists and Diagnostics
Initiative, Clinical Pathways, Surgical Variation and Appropriateness Working Group,
Synoptic Reporting for breast cancer and lower leg bypass surgeries. Embedding the
Appropriateness of Care Framework and methodology into these initiatives can ensure
that patients receive the right care, provided by the right providers, in the right place, at
the right time resulting in optimal quality of care.
Appropriateness of Care Framework 9 Version 1: December 4, 2015
As previously mentioned, the Choosing Wisely Canada (CWC) campaign was launched in
April 2014 to help physicians and patients engage in healthy conversations about
unnecessary tests, treatments and procedures, and to help physicians and patients make
smart and effective choices to ensure high-quality care. Since its launch in 2014, more than
150 recommendations have been produced on various treatments, as well as 50 patient
education pamphlets. Given that the Saskatchewan Medical Association (SMA) is fully
onboard with this campaign, there is opportunity for the Saskatchewan health system to
collaborate with the SMA to leverage this campaign to improve Appropriateness of Care
in Saskatchewan.
The Saskatchewan Center for Patient Oriented Research (SCPOR) has been formed to
develop a patient-oriented research (POR) strategy for the Saskatchewan health system,
which will be part of the Canadian Institute of Health Research (CIHR)’s nation-wide POR
strategy in Canada. The SCPOR group is comprised of researchers and academic research
organizations (University of Saskatchewan, University of Regina, First Nations University,
Saskatchewan Polytechnic, and HQC). Appropriateness of Care has been identified as one
of their core priorities. SCPOR will be partnered with the provincial Appropriateness of
Care Program, Regional Health Authorities (RHAs), the Saskatchewan Cancer Agency
(SCA) and other health care organizations to integrate the research components into
Appropriateness of Care, which will ensure that the care provided to patients is evidence-
based.
The opportunities are vast with linkages to many ongoing initiatives in the Ministry of
Health, RHAs, SCA, 3sHealth, individual clinicians and other health care organizations
that have a burning interest to improve care, as well as many external organizations.
Moving Forward with Appropriateness of Care in Saskatchewan
“The framework and standard work for Appropriateness is so important, so that information
given to patients is clear- from primary care givers to specialists. Of
course, there will always be differing opinions among doctors, but
patients can make better decisions when armed with good (more
standard) information. We can be more involved in the decision
making.”
- Cindy Dumba, a Patient and Family Advisor
Appropriateness of Care Framework 10 Version 1: December 4, 2015
1. System-wide adoption of a common methodology for improving
Appropriateness of Care
A number of high performing health care systems in the US have been successful in their
work on improving Appropriateness of Care by reducing clinical practice variation,
including Intermountain Healthcare in Salt Lake City, Utah and Virginia Mason Hospital
and Medical Centre in Seattle, Washington. As part the Appropriateness of Care
Framework, a Saskatchewan model of improving Appropriateness of Care has been
developed based on the methodologies used by these organizations: a clinician-led,
evidence-based, data-driven and continuous- learning approach to improving
Appropriateness of Care.
Appropriateness of Care projects will each be led by a Clinical Development Team of
frontline clinicians (specialists, family practitioners, nurses, pharmacists, etc.)
administrative/support staff, data experts, researchers, patients and their families. Clinical
Development Teams will implement common agreed-upon best practices while measuring
and analyzing data required to measure outcomes including clinical, safety, service and
cost. An important part of the implementation process is that both the common agreed-
upon practices and measurements need to be built into the clinical workflow. This will
make it easier for clinicians to use the agreed-upon best practices and to track the progress
and outcomes. Using Plan Do Study Act (PDSA) tools, feedback received from clinicians
will be reported back to the Clinical Development Team for further improvement in
agreed-upon best practices (See Appendix F: Implementation Process for AC
Methodology).
2. Provincial, Regional and Organizational Structures for Appropriateness of Care
Successful implementation and integration of the provincial Appropriateness of Care
Framework into the Saskatchewan health care system is dependent on the creation of not
only a provincial strategy, but also a plan within each health region and health care
organization to support the framework’s methodology (depicted in Figure 1 on page 18).
Provincial, regional and organizational level requirements include physician champions
(part-time), staff to support data collection and analysis, as well as administrative support.
Major risks of implementing the Appropriateness framework without system supports
include delays in implementation, limited or poor results, and disengaged physicians who
will be reluctant to re-engage in the future.
The provincial level structure includes the Provincial Appropriateness of Care program.
The program, established in 2015, has a formal governance and decision making structure
(Appendix E), to support provincial Appropriateness of Care projects. A provincial
Appropriateness of Care Framework 11 Version 1: December 4, 2015
Appropriateness of Care project will be a larger scale project affecting a significant portion
of population in Saskatchewan or several health regions. The roles and responsibilities of
the Provincial Appropriateness of Care program include:
integration and coordination of all Appropriateness of Care efforts across the
system;
support health regions and other health organizations to begin their
Appropriateness of Care program (e.g. provide facilitation, consultation, data
support, and education and training);
lead, coordinate, replicate provincial Appropriateness of Care projects;
monitor and measure the progress and outcomes;
increase awareness of Appropriateness of Care (e.g. stakeholder engagement,
public awareness campaign, communication, etc.); and
ensure that Appropriateness of Care work is aligned with provincial priorities and
initiatives.
Individual health regions and other health care organizations interested in pursuing
Appropriateness of Care may require regional/organizational support to implement the
Appropriateness of Care program. This support could include Appropriateness of Care
leads (one physician lead, one administrative lead such as a vice president) that are
passionate, and knowledgeable about Appropriateness of Care issues and quality
improvement methodologies. The roles and responsibilities of the regional programs may
include:
selecting targeted clinical areas for Appropriateness of Care projects within the
organization;
implementing Appropriateness of Care projects;
replicating the projects to other areas and sharing results with other regions and
agencies;
monitoring and measuring the progress and outcomes; and
providing ongoing communication with the senior leadership team and those who
will be impacted by the Appropriateness of Care projects.
Individual regions and organizations may need to leverage existing resources and
structures such as the Lean Management System (e.g. Kaizen Promotion Offices, Kaizen
Operation Teams, and various Lean quality improvement tools). This will benefit
implementation of the framework and mitigate duplication/addition of resources within
the organization.
To ensure success, it is important that all health regions and organizations have a shared
understanding of the Appropriateness of Care Framework, use the same methodology and
tools for improving Appropriateness of Care, and work collaboratively toward achieving
Appropriateness of Care Framework 12 Version 1: December 4, 2015
the provincial goals and targets. A Provincial Appropriateness of Care Network will be
established to facilitate this system-wide adoption and will coordinate all Appropriateness
of Care work across the system.
Members of Network will include the Provincial Appropriateness of Care team,
representatives from all 12 health regions, SCA, HQC, eHealth Saskatchewan, Ministry of
Health (MoH) and 3sHealth, SCPOR as well as patient and family advisors. Those
regional representatives will be the ones who will lead Appropriateness of Care work
within their organization. The main roles and responsibilities of this group may include:
information-sharing (innovative ideas, success stories, and lessons learned from
individual regions’ Appropriateness of Care work);
coordinating Appropriateness of Care efforts across the system;
suggesting provincial priorities for improving Appropriateness of Care;
ensuring that all health regions and organizations use the common methodology
for improving Appropriateness of Care; and
using common indicators to measure the provincial Appropriateness of Care
outcome and improvement targets.
Appropriateness of Care Framework 13 Version 1: December 4, 2015
Figure 1
RHAs/SCA/3sHealth AC Program
Provincial AC Program
Selection and implementation of regional AC projects
Replication of the projects to other areas
Monitor and measure the progress and outcomes
Communicate with those who will be impacted by the AC projects
Coordinate AC projects with other regions and organizations
Data Support (eHealth,HQC,MoH)
Integration and coordination of all AC efforts across the system
Support RHAs/SCA to begin their AC program (facilitation, consultation, data support, education and training)
Lead or coordinate provincial AC projects
Monitor and measure progress and outcomes
Increase awareness of AC
Implement the Appropriateness of Care Data Strategy
Assist regions, SCA and the provincial AC program in collecting, analyzing and reporting data
SCPOR
Provincial AC Network
Information sharing (ideas and lessons learned from individual regions’ AC works)
Coordination of AC efforts across the system
Setting provincial priorities for AC
Common methodology for improving AC
Common indicators to measure the AC outcomes
Provide research support to both regional and provincial AC projects (literature review, best practices, e-scan, etc.)
Conduct a research on AC projects and share the results with AC teams
Provincial, Regional and Organizational Structures for Appropriateness of Care
3. System-Wide Support Structure for Appropriateness of Care
Implementation of the provincial Appropriateness of Care framework initiates another
transformational culture change in health care: clinicians, patients and the health care
system will have key roles to play in recognizing when medical care is too much, too little,
or the wrong care. Changing the current clinical culture has already proven to be
challenging. The following three elements are the foundation that will help address
Appropriateness of Care Framework 14 Version 1: December 4, 2015
anticipated barriers and support the implementation of the Appropriateness of Care
framework across the system.
a) An Involvement Strategy
A comprehensive strategy to involve stakeholders at all levels is critical to successful
implementation as well as to achieve the culture change required to sustain
momentum and any improvements. The key stakeholders of the Appropriateness of
Care program include clinicians, health care system leaders, providers, researchers,
patients, families and the public. Plans for involving individual stakeholder groups
have been developed and they will be implemented over the next few years. Key goals
and actions exist for involving each stakeholder group.
Health System Leadership and Provider Involvement Strategy
The goal is to create an environment where physicians and other health care
professionals are supported to implement the Appropriateness of Care
Framework within their own organizations and their own practices. A series of
presentations to raise awareness of Appropriateness of Care work were given in
late 2014-15, delivered to various health system leadership groups, including the
Provincial Leadership Team (PLT), the Ministry of Health Senior Leadership
Team (SLT), Senior Medical Officers Committee (SMOC) and a variety of
physician groups. This action will continue throughout 2015-16 to engage other
health system leaders, continue to create awareness and solicit their support for
implementing the framework in their own regions and organizations.
Physician Involvement Strategy
Physicians play a key role in the health system, and are integral to quality of
care, patient safety, and system leadership. Their commitment and participation
are key to achieving cultural transformation. The goal of the physician
involvement strategy is to create an environment that supports physician
leadership and education in improving Appropriateness of Care. As part of the
engagement strategy, key guiding principles and tools for involving physicians
have been developed to facilitate physician involvement in Appropriateness of
Care projects. A number of physician leadership groups, including Practitioner
Advisory Committees, Department Heads at Regina Qu’Appelle and Saskatoon
Health Regions, and the SMA have been engaged in discussion on improving
Appropriateness of Care in Saskatchewan. In order to ensure ongoing
involvement, existing physician compensation policies and models are being
reviewed to address barriers for involving physicians, and to create an incentive
structure that will motivate involvement.
Appropriateness of Care Framework 15 Version 1: December 4, 2015
Patient, Family and Public Engagement Strategy
The goal of this strategy is to create a collaborative partnership with patients
and families in improving Appropriateness of Care. This means involving
patients and families in designing and implementing any efforts to improve
Appropriateness of Care, as well as involving them in their own care and
treatment decision-making, ensuring that their perspectives are incorporated.
To increase patient involvement in their own treatment decision-making at the
level they choose, Shared Decision-Making (SDM) concepts and tools will be
embedded into applicable Appropriateness of Care projects, allowing patients’
values and preferences to be incorporated into their treatment plan.
Most health regions and other organizations have structures to involve patients
and families in improving quality of care and patient safety. A number of
patient and family advisors and advisory councils have been involved in
various quality improvement initiatives at the regional level and the provincial
level. Appropriateness of Care will leverage these existing structures to involve
patients and families.
Effective communication with these stakeholders will be an important part of the
engagement strategies. Multi-modal communication techniques and tools will be used
to inform and update stakeholders on various initiatives underway, successes and
lessons learned. This will not only help them stay engaged but also will keep the
momentum going for continued improvement.
For more detailed engagement and communication plans for individual stakeholders,
see the supporting appendices (Appendix B: Physician Involvement Plan; Appendix C:
Stakeholder Engagement Plan).
b) A Robust Clinical Information System
Successful implementation of the provincial Appropriateness of Care Framework is
dependent on the availability of relevant clinical information to support continuous
learning and improvement. Ability to access reliable and timely clinical data will not
only display the current state of particular clinical areas (i.e. identifying clinical practice
variation, any Appropriateness of Care issues and any practice changes needed to
improve Appropriateness of Care) but also measure the impact of practice changes and
improvements made on patient outcomes.
Appropriateness of Care Framework 16 Version 1: December 4, 2015
Although Saskatchewan has a number of rich health databases that can be used for
quality improvement and clinical research (e.g. Discharge Abstract Database, MDS,
etc.), the process for obtaining timely data can be complicated, challenging and
expensive. The development of valuable clinical information systems requires
leadership, methodology, human resources and infrastructure support. A data and
measurement strategy has been developed in collaboration with eHealth Saskatchewan
to address issues related to accessing reliable and clinically relevant data for
Appropriateness of Care. Much of this work will focus on increasing awareness and
accessibility of data, human resource and infrastructure capacity for measurement
system design, and governance for the data strategy (i.e. clear roles and responsibilities
of all participating organizations).
c) Education and Training Programs
Education and training is a very important component for building capacity to
improve Appropriateness of Care within the system. Education and training will not
only support the system to achieve Appropriateness of Care provincial targets but also
facilitate the culture change needed to make Appropriateness of Care a norm in clinical
practice. Several physicians and quality improvement experts in Saskatchewan have
completed the Intermountain Healthcare Quality Improvement Training called
Advanced Training Program (ATP). This program provides in-depth knowledge and
tools for improving Appropriateness of Care in various clinical areas.
Education and training based on the Intermountain Healthcare model will be
developed and implemented over the next few years. They will highlight the value of
patient outcomes tracking and continuous quality improvement in order to identify
and improve the care provided to patients.
Once developed, education and training will be provided to clinicians, administrative
staff, data experts, patients and families who will be part of developing and
implementing Appropriateness of Care projects at both the regional and the provincial
levels. Further, educational components ideally will be integrated into Lean for
Improvement Leader Training as well as embedded into the College of Medicine
curriculum, residency training programs, professional development workshops, and
Continuing Medical Education (CME) so that Appropriateness of Care becomes routine
practice.
Appropriateness of Care Framework 17 Version 1: December 4, 2015
Next Steps
In order to achieve the ambitious goals around Appropriateness of Care in Saskatchewan,
the framework has been developed to provide a strategy for embedding the
Appropriateness of Care methodology into the Saskatchewan health system. The
framework is expected to be implemented over the next several years and will require the
collaborative action and support of the entire health system: leaders, clinicians,
administrators, patients and their families, to continue to work together on this major
transformational culture shift in “what” care is provided in Saskatchewan.
The next several years will be a learning experience for the health care system in
Saskatchewan. Lessons learned over the course of 2015-16 with the MRI of lumbar spine
work will contribute to modifications and refinement of the Appropriateness of Care
Framework. The goal of changing the culture will evolve over time, given the will,
commitment, and patience of the system as this program spreads its roots and becomes
embedded in the daily work of providing health care.
The elements of the Provincial Appropriateness of Care Framework are illustrated in a one
page schematic diagram on page 18.
Appropriateness of Care Framework 18 Version 1: December 4, 2015
Appropriateness of Care Framework Better Care Made Easier
Appropriateness of Care Framework Better Care Made Easier
Vision: "The Right Care, provided by the Right Providers, to the Right Patient, in the Right Place, at the Right Time, resulting in Optimal Quality Care (CMA Definition)."Outcome Target: By March 31, 2018, 80% of clinicians in 3 selected clinical areas within two or more service lines will be utilizing agreed upon best practices.Improvement Target: By March 31, 2016, at least one clinical area within a service line will have deployed care standards and will be actively using measurement and feedback to inform improvement.
Targeted Patient-Centred Clinical Area Development & Implementation Process
Establish a Development Team Physician & Administrative
Lead Knowledge experts Analyst support Set timeline
Establish Common Agreed-Upon Practices & Define the Data Required to Measure Outcomes (Clinical, Service, Financial) Set timeline
Implement the Common Agreed Practices
Communication, Embedding Data in the
Clinical Work Flow Education and Training Set timeline
Monitor, Evaluate and Revise as Required Set timeline
Identify Projects within the Targeted Clinical Area Set timeline
Syst
em W
ide
Sup
po
rts
Governance and Decision Making Governance Structure for Accountability (i.e. Monitoring,
Evaluation, Reporting) Integrate & Coordinate with System Priorities Identify & Prioritize Clinical Areas of Interest (i.e. Process for
Responding to/Supporting Improvement Ideas) Replication Celebrate Successes
Regional/SCA Appropriateness of Care Project Leadership & Support
Governance & Decision Making Project Identification & Selection Quality Improvement Support Resources (Financial and HR)
Monitoring and Reporting
Provincial Appropriateness of Care Program and Project Leadership & Support
Hea
lth
Sys
tem
Ap
pro
pri
aten
ess
of
Care
Appropriateness of Care Program Advisory Support to RHAs/SCA
and Others
Appropriateness of Care Program Advisory Support to RHAs/SCA
and Others
Clinical Information System Data Infrastructure and Warehouse Integration with Electronic Medical Record (EMR) and
Electronic Health Record (eHR) Measurement Development
Involvement Strategy Physician Involvement Patient/Public Involvement Shared Decision Making Partnerships with Key Stakeholders (e.g. RHAs, SCA,
eHealth, 3sHealth, SMA, etc.) Communication Strategy Culture Change
Education and Training Education and Development of Clinical Leaders Training for New Tools/Technologies Patient/Public Education Integration and Partnerships with Healthcare Education
Institutions (e.g. College of Medicine)
Appropriateness of Care Framework 19 Version 1: December 4, 2015
References
Brien, Susan; Gheihman, Golina et al. A Scoping Review of Appropriateness of Care
Research Activity in Canada from a Health System-Level Perspective. Healthcare Policy
Volume 9 No. 4 2014.
Brook, Robert H. Assessing Appropriateness of Care- It’s Time has Come. JAMA September
2, 2009 302(9):997-998.
Brook, Robert H. The RAND/UCLA Appropriateness Method. Santa Monica, CA: RAND
Corporation, 1995. http://www.rand.org/pubs/reprints/RP395.
Bunker, John P. Variations in Hospital Admissions and the Appropriateness of Care: American
Preoccupations? BMJ September 1990
Canadian Medical Association. Choosing Wisely Canada. 2013. choosingwiselycanada.org
Canadian Institute of Health Improvement:
CIHI Health Indicators 2011; 2012
Breast Cancer Surgery in Canada; 2007-08 to 2009-10
Council of Federation. From Innovation to Action: The First Report of the Health Care
Innovation Working Group. 2012
Dagnone, Tony. For Patients’ Sake: Patient First Commissioner’s Report for Saskatchewan
Minister of Health. October, 2009
Farquhar, Cynthia. Clinicians’ Attitudes to Clinical Practice Guidelines: A Systematic
Review. The Medical Journal of Australia. August 2002
Fuchs, Victor R. The Doctor’s Dilemma- What is “Appropriate” Care? NEJM August 18,
2011.
Health Quality Council Ontario: Appropriateness Initiative. www.hqontario.ca
James, BC; Savitz LA. How Intermountain Trimmed Health Care Costs through Robust
Quality Improvement Efforts. Health Aff (Millwood). June 2011. 30(6):1185-91.
Appropriateness of Care Framework 20 Version 1: December 4, 2015
Larson, Elise; Ko, Clifford et al. Appropriateness Criteria to Assess Variations in Surgical
Procedure Use in the U.S. JAMA Surgery. December 2011
Lee, Clara; Ko, Clifford. Beyond Outcomes- The Appropriateness of Surgical Care. JAMA
October 14, 2014. Volume 302 No. 14.
McNeil, Barbara J. Hidden Barriers to the Improvement of Quality of Care. NEJM November,
2001
Mecklenburg, Robert. Cutting Costs of Care While Improving Quality. Parts One and Two.
Virginia Mason Blog December, 2014
Saskatchewan Surgical Initiative. Population‐Based Variation in Rates of Surgical
Interventions in Saskatchewan: A First Look at Province‐Wide Data. Saskatchewan Surgical
Variation and Appropriateness Working Group 2012
Stacey D, Bennett LC, Barry JM, Col FN, Eden BK, Holmes-Rovner M, Llewellyn-
Thomas H, Lyddiatt A, Légaré F and Thomson R. Decision Aids for People facing Health
Treatment or Screening Decisions. Cochrane Database of Systematic Reviews. 2011. Issue
10.
Appropriateness of Care Framework 21 Version 1: December 4, 2015
Appendix A: Opportunities to Align Appropriateness of Care with Provincial Initiatives
Appropriateness of Care
Spe
cia
lty
Ca
re
Primary Health Care
Long-te
rm Care
Home Care
Ho
spita
l Ca
re
Emergency CarePreventing harm to patients
during hospital admission (e.g. hospital acquired infections and
medication errors)
Appropriate hospital length of stay
Overuse/underuse of diagnostic testing and cancer screening
Patients are not always seen by the right providers.
Clinical practice variation
Polyphamacy and adverse drug events in patients with multiple chronic conditions
Overuse and misuse of Antibiotics
Need more community supports for seniors to remain in their own
homes independently
Underuse of effective treatments for patients with chronic diseases
Overcrowded ED resulting in long waits to be seen and be treated
Over-prescribing to Seniors in LTC (overuse of antipsychotic medication, sleeping pills, etc.)
Need adequate End of Life Care services for patients with terminal illness and
seniors (avoid patients dying at the ICU receiving aggressive life sustaining
procedures)
Underuse of advance care planning for patients with terminal illnesses and seniors
Need for evidence-based, coordinated care that
improves patient experiences and outcomes
Overuse of unnecessary diagnostic imaging test (i.e.
MRIs, CT, etc.)
Home First/Quick Response Home Care
Underuse of preventative treatment/programs for at
risk population
ED Waits and Patient Flow
Monitoring the use of antipsychotic medications without a diagnosis at LTC
Hotspotting (ED Waits and Patient Flow)
FASD Prevention Program
Clinical Pathways (Hip & Knee, Prostate, Spine, Pelvic Floor,
Lower Extremity Wound, Acute Stroke)
Wait 1 (eReferrral, Pooled Referral,
Specialist Directory, Link/non-urgent telephone consultation between Family doctors and
specialists)
CDM-QIP, LiveWell™ with Chronic Conditions,
Provincial Diabetes Plan
MRI of Lumbar Spine Project
Surgical Site Infection Prevention Bundle. Surgical
Safety Checklist
Medication Reconciliation Program
Variation and Appropriateness Working Group (VAWG)
The Enhanced Preventative Dental Services for Children
HIV Strategy
Publicly funded immunization program
Collaborative Emergency Centres
High volumes of ALC patients/seniors occupying Acute Care beds
ALC Strategy (ED Waits and Patient Flow)
Early Facilitated Discharge (ED Waits and Patient Flow)
Pharmaceutical Information Program (PIP)
Prescription Review Program, Prescriptive Authority Program,
SK Medication Assessment Program
Appropriate Use of STI Medications
RX Files Long-Term Care Project
Seniors’ House Call (ED Waits and Patient Flow)
Interdisciplinary Team Rounds (ED Waits and
Patient Flow)
Appropriateness of Care Framework 22 Version 1: December 4, 2015
Appropriateness of Care Framework: Physician Involvement Strategy
Appendix B: Physician Involvement Strategy
Appropriateness of Care: Better Care Made Easier
Appendix B: Physician Involvement Strategy
Appropriateness of Care Framework 23 Version 1: December 4, 2015
Physician Involvement Strategy
“The endless pursuit to find the miracle solution simply points to the reality that there isn’t one solution that fits everyone….We are all going to have to work on this one.”13
1. Introduction
Successful implementation of the Appropriateness of Care framework is dependent on
engagement of a large contingent of stakeholders across the health care system.
Physicians play such a key role in the health system, and are so integral to quality of
care and patient safety, that a strategy for involving physicians in the Saskatchewan
Appropriateness of Care program is essential for the initiative’s success.
“Very few decisions about the clinical care of patients can be made without a physician’s
order. They have knowledge that others do not; they are at the heart of care; they have
power; they control resources and without them and their support, nothing moves
forward.”14
Many Canadian provinces are addressing quality of care and patient safety in a
systemic way, however obtaining physician involvement in system improvement
continues to be a challenge.15 Health system leaders are unlikely to achieve system-level
improvement without physicians and physicians cannot bring about system-level
performance improvement alone, but can prevent it from moving forward.16
The term “physician engagement” is currently a popular and overused term that is
heard frequently in conversations about health care reform, however the phrase is not
always clearly defined or understood, therefore has different meanings to different
stakeholders. Often the term physician engagement is used interchangeably with the
term physician leadership. In order to successfully improve Appropriateness of Care in
Saskatchewan, both physician engagement, defined as physicians’ active interest and
participation, and leadership are critical. One of the key guiding principles for the
provincial work on improving Appropriateness of Care is for the work to be clinician
led; therefore, physicians need to be actively involved throughout the entire journey of
implementing the Appropriateness of Care program.
13 Knowling Robert. Leading with Vision, Strategy and Values. Chap 15 in Leading for Innovation and Organizing for Results.2010
14A Roadmap for Trust: Enhancing Physician Engagement. Amer Kaissi. Written for RQHR 2012
15 Improving Care for British Columbians: The Critical Role for Physician Engagement. Julian Marsden et al. Healthcare Quarterly
15 (Special Issue): December, 2012. 16
Seven Leadership Leverage Points. IHI Innovation Series 2005
Appendix B: Physician Involvement Strategy
Appropriateness of Care Framework 24 Version 1: December 4, 2015
Physician involvement depends on multiple factors, can be difficult to achieve, and
won’t happen without focused efforts. Diverse strategies must be considered – the
strategies may vary depending on various groups, as well as the dynamics and
relationships of the groups. Creating an environment that creates a true partnership
with our physicians in improving Appropriateness of Care includes understanding
their perspective, seeing health care from their eyes and learning from them,
particularly those physicians who are already highly involved.
There is no “one size fits all” or “recipe for success” strategy that can be universally
applied for individuals or group of physicians. Trust between physicians and
organizations must be established; trust will develop around open communication,
creating a shared vision, willingness to share relevant data, and evidence of successful
collaboration.17
There have been numerous publications suggesting the importance of physician
engagement and leadership; however few publications discuss the processes by which
health systems and organizations can convert physician autonomy, knowledge and
power into resources for health system performance and improvement.18 There are very
few Canadian publications documenting successful results of engagement strategies.
Many articles suggest one strategy to create a culture of physician engagement is
encouraging and empowering physicians to take the lead on a wide range of quality
improvement initiatives.19 What better quality initiative than Appropriateness of Care?
One of the first action items already implemented by Saskatchewan senior leaders is
recognition that development of the Appropriateness of Care framework requires
significant physician input. This has resulted in appointment of two highly regarded
physicians who hold senior leader roles as program sponsors, and two highly engaged
physicians with significant knowledge of quality improvement theory appointed to lead
development of the framework and act as expert resources to guide the process of
physician engagement.
The challenge of increasing physician involvement to improve Appropriateness of Care
is a process that will take time, will evolve, and will be dependent on persistence and
continuous evaluation of what’s working well, and what can be done better. Facilitation
in shifting the thinking from getting “buy-in” to “ownership” is a key factor and
17
Exploring the Dynamics of Physician Engagement and Leadership for Health System Improvement: Prospects for Canadian Healthcare Systems. Final Report. April, 2013 Ross Baker et al 18
A Roadmap for Trust: Enhancing Physician Engagement. Amer Kaissi. Written for RQHR 2012 19
Policy Paper: Partnering with Physicians: Doctors of BC January, 2014
Appendix B: Physician Involvement Strategy
Appropriateness of Care Framework 25 Version 1: December 4, 2015
challenge; however if successful, the results will be extremely influential and beneficial
for the initiative.
Implementation of the Appropriateness of Care framework is a process that will take
many years to be fully embedded in the daily work of the health care system and
physician work flow. The Appropriateness of Care program must provide a compelling
argument that attracts physicians’ interest and answers the question that physicians will
ask themselves, “What’s in it for me and my patients?” If the answer to that question
provides a compelling enough argument, the Appropriateness of Care program will
gain traction quickly.
2. Guiding Principles
Guiding principles for physician involvement were developed by Dr. T. Josdal, Chief
Medical Officer for Saskatchewan and Appropriateness of Care Program sponsor.
These principles will be used to guide involvement of physicians:
Physician Engagement is defined as “the initial, ongoing, energetic, and
committed involvement of physicians in their diverse working roles within the
health system.”20 If an initiative or process is likely to affect physician workflow,
or clinical work, they must be involved.
Involve physicians from the beginning, and continuously thereafter.
Dialogue and involvement create an atmosphere conducive to engagement but
do not constitute engagement by themselves. The alignment with organizational
goals is a key part of engagement.
Dyad (physician leader integrally coupled with an operations leader) and other
co-leadership partnerships create meaningful working relationships. Their value
is beyond engagement, and benefits operations and patient safety.
Strong evidence, in proposals for change, dramatically helps to engage
physicians in changes to clinical processes.
Reduction of hassles and wasted time are strong catalysts to assist with change.
Understanding the culture of the physician group is essential in order to move
forward. If there are significant outstanding unresolved issues, engagement will
not likely occur.
Clarity around responsibilities of the health system/RHA, and of each and all
physicians is fundamental to alignment with the quality agenda.
Making it easy to do the right thing is a win-win situation for all, and should be a
cornerstone for many quality improvements.
20
Anchoring Physician Engagement in Vision and Values: Principles and Framework. G. Dickson for RQHR 2012
Appendix B: Physician Involvement Strategy
Appropriateness of Care Framework 26 Version 1: December 4, 2015
Communicate well and appropriately, never wasting a physician’s time. Links to
information are useful, and can be selected, or not.
Distributed Leadership, where a committee or group empowers and assists each
member to become a conduit for communication and feedback. This fosters
leadership and engagement of not only the member of the committee/group, but
also the physicians contacted by the committee member.
Leadership education and training helps leaders to hone skills around
engagement, while recognizing that informal leaders are also very helpful in
engaging physicians.
Action Plans and Timelines are essential pieces when engaging physicians,
because they have a keen sense of wasted time and energy when applied to
quality initiatives.
Celebrate successes. Demonstrate success in eliminating wasted time and
energy, while improving care and making work easier for clinicians.
Create time spaces that work for clinicians if you wish them to become engaged.
This applies to meeting times and travel.
Private physician overhead costs must be considered when planning to engage
physicians.
Trust and follow-through are essential values for the promotion of ongoing
engagement. If a physician feels betrayed and becomes disengaged, re-
engagement is difficult or impossible.
The above listed principles mirror IHI’s Framework for Involving Quality and Safety
very closely.
Appendix B: Physician Involvement Strategy
Appropriateness of Care Framework 27 Version 1: December 4, 2015
Figure 1: IHI’s Framework for Involving Physicians in Quality and Safety- checklist21
3. Key Drivers and Actions
These Guiding Principles, IHI’s Framework for Engaging Physicians in Quality and
Safety checklist, and the Driver Diagram illustrated in Figure 2 below have been used to
develop the physician engagement action plan for the Appropriateness of Care
program.
21
Reinertsen et al 2007 IHI
Appendix B: Physician Involvement Strategy
Appropriateness of Care Framework 28 Version 1: December 4, 2015
Figure 2: Physician Involvement Strategy
To create a culture that supports physician involvement in
improving Appropriateness of Care (AC)
Provide Education and Training
Increase Awareness of AC related Issues and the framework
Provide Incentives to be Involved in Appropriateness of Care
Recognize and Reward the Successes
Involve Physicians in Governance and Decision Making
Develop communication mechanisms to share the successes and lessons learned from AC projects
PHYSICIAN ENGAGEMENT GOAL KEY DRIVERS ACTIONS
Develop a governance and decision making structure that reflects the physician led program
Ensure that all individual AC projects are led by physicians
Identify and develop physician champions who can advocate for AC
Develop a process to gathering physician input in selecting the next AC projects and priority areas
Conduct road shows to increase awareness of AC work among various physician groups across the system
Work with SMA to align AC work with the “Choosing Wisely Campaign
Develop communication tools to increase awareness of AC projects and share agreed practice guidelines and tools developed under the AC
program
Develop an education and training program similar to the Intermountain Health program
Embed the AC framework and training modules into the medical school curriculum
Provide CME Credits to those involved in the Development Team
Standard compensation policy for involving physicians in AC projects
Work with the Ministry of Health to develop an incentive structure for physicians to use AC’s agreed upon practice guidelines and tools
Involvement in Governance and Decision Making
Involving physicians in formal leadership roles and formal decision-making or
governance bodies is important (however that strategy alone won’t result in
greater physician engagement). Recent research focused on developing more
effective clinical practice settings suggests that structure can play an important
role in generating physician engagement and physician leadership. It also
suggests that engaging the medical profession and developing its leadership
cannot be limited to initiatives located at the strategic apex of the organization or
system.
Structures creating greater alignment for improvement, accountability and cost
containment may represent fertile ground for developing physician
Appendix B: Physician Involvement Strategy
Appropriateness of Care Framework 29 Version 1: December 4, 2015
involvement.22 Actions taken to date and future actions to involve physicians in
governance and decision making include:
The Appropriateness of Care program sponsors include two physicians who
are senior provincial leaders- the provincial Senior Medical Officer and the
current Chair of the Saskatchewan Health Quality Council.
The Appropriateness of Care Steering Committee was established to provide
strategic direction and oversight for the provincial Appropriateness of Care
program. The Steering Committee is comprised of the above listed
physicians as well as senior leaders from the health system, including senior
medical officers from the Regina Qu’Appelle health region (RQHR) and the
Saskatoon health region (SHR) as well as the Dean of the College of Medicine.
Two physicians have been appointed as co-leads for development of the
framework, as well as an administrative co-lead, working in a dyad
leadership model.
Formation of the first Appropriateness of Care Development Team for MRI of
lumbar spine includes physician representatives who are the key
stakeholders in utilization of this modality of testing. The group is comprised
of representatives from orthopedic surgery, neurosurgery, radiology and
family practice.
A necessary next step will be to identify how the Appropriateness of Care
project team can provide support to the key stakeholders (i.e. RHAs and
SCA) as they start work on various Appropriateness projects- what structures
and supports will be required in each agency to ensure success?
Awareness of Appropriateness of Care and the framework
The Appropriateness of Care program aligns strongly with physician’s clinical
work. Quality initiatives that impact clinical work are more appealing for
physician involvement. Continuing to raise the level of awareness about the
Appropriateness of Care program may increase the desire to be involved.
Actions to date and in the future actions include:
A series of presentations to raise awareness of Appropriateness of Care was
initiated in late 2014-15. Information has been presented to several groups of
physicians including: SHR Department of Radiology, SMA Section of Family
Practice, SHR Practitioner Affairs Committee, RQHR Department Head
Council and Practitioner Affairs Committee, SaskDocs, and Saskatchewan
International Physician Practice Assessment (SIPPA).
22 Baker, Dr. Ross et al. Exploring the Dynamics of Physician Engagement and Leadership for Health System
Improvements: Prospects for Canadian Healthcare Systems Final Report. April 2013
Appendix B: Physician Involvement Strategy
Appropriateness of Care Framework 30 Version 1: December 4, 2015
This action will continue throughout 2015-16 reaching out to various other
physician communities to increase awareness of the Appropriateness of Care
framework, share agreed upon clinical practices and tools with physicians as
well as successes and lessons learned from Appropriateness of Care projects.
Ongoing collaboration with SMA in aligning Appropriateness of Care with
the Choosing Wisely Canada campaign
Developing and implementing a mechanism to hear physicians’ voices and
concerns about the implementation of Appropriateness of Care (e.g. annual
physician surveys)
Developing awareness of Appropriateness of Care related issues includes
collaborating with groups that have the ability to influence others to advance
the agenda of improving patient/client/resident care (See Section 5: Using
Physicians to Influence Change)
Education and Training
Education about Appropriateness of Care, as well as training in the improvement
methodology will increase physician involvement. Actions to date and future
actions include:
Develop a lecture on Appropriateness of Care to be tested in the College of
Medicine in 2016-17
Provide education and training to RHA and other health care organizations
about the Appropriateness of Care framework and how to implement it in
clinical areas
Work with HQC and the SMA in supporting physicians to enroll in the
Intermountain Health Advanced Training Program (ATP)
Align with the SMA to develop mechanisms and tools to educate the public
about Appropriateness of Care by leveraging patient information developed
by the Choosing Wisely campaign (e.g. posters, brochures, media
advertisements, website, social media)
Develop a Saskatchewan based educational program for physicians who are
interested in participating in Appropriateness of Care projects i.e.
Intermountain sister course (2017-18)
Work with the College of Medicine to embed education regarding
Appropriateness of Care into the medical school curriculum (2018-19)
Provide advice/assistance to RHAs and SCA in setting up a quality
improvement structure to undertake Appropriateness of Care projects within
their organization
Appendix B: Physician Involvement Strategy
Appropriateness of Care Framework 31 Version 1: December 4, 2015
Provide Incentives to be Involved in Appropriateness of Care Work
There must be a compelling incentive for physicians to become involved in
Appropriateness of Care work, which may mean financial incentives, time, and
the opportunity to improve efficiency of daily workflow.
Remuneration will be provided to physicians participating in Clinical
Development Teams. A standard process and rate will be applied.
Policies regarding physician remuneration may have to be revised.
Recognize and Reward Successes
Provide thanks to Development Team members, including formal
acknowledgement by CEOs, VPs, and senior physician leaders in the form of
a letter of thanks, or an email.
Find ways to share the results/outcomes for each Clinical Development Team
(e.g. websites, newsletters, email, social media- depending on the results and
targeted audience)
Tap into professional newsletters to share outcomes (i.e. SMA and College of
Physicians and Surgeons of Saskatchewan newsletters)
Celebrate success through sharing the results in local, provincial and national
publications
Nominate outstanding work for local and provincial quality awards
4. Lessons Learned to Date
Physician input is critical for selection criteria and the decision making process
for upcoming/future Appropriateness of Care improvement projects.
Identify physicians with a keen interest in the clinical area (physician champions)
Ask for volunteers to participate in the Development Team; some may need to be
tapped on the shoulder
Obtain endorsement of senior physician leaders, and then make them aware of
physicians who are involved
Keep senior leaders regularly updated on progress, successes and challenges
Ensure that senior leaders provide the authority for Development Teams to make
decisions and that Development Teams are aware of that authority
Provide related data and a best practice literature search as a conversation starter
Provide an orientation for Development Team members: make it brief with clear
statement of purpose; outline accountabilities
Include terms of reference- discuss how decisions will be made
Arrange meetings by consensus: time, date, frequency
Consider using Telehealth as an alternative to face to face meetings
Appendix B: Physician Involvement Strategy
Appropriateness of Care Framework 32 Version 1: December 4, 2015
Shorter more frequent meetings may be better received than lengthy meetings,
depending on meeting purpose
Be concise with information provided: meeting agendas and deliverables;
circulate material ahead of time
Allow time for discussion and for team members to voice their opinions
Ensure that Development Team members are aware of the remuneration rate for
participation and provide support for the process to obtain payment
Provide information regarding Continuing Medical Education credits that
physicians may be eligible to claim by participating in this work
Be transparent if there are concerns with discussions
Don’t preplan meeting outcomes
Providing food/beverages is a nice gesture depending on meeting time
Identify potential problems, discuss them, and work on solutions collectively
Record meeting minutes, decisions and action items and distribute in a timely
manner
Develop an overall physician communication plan: the plan should include
specific written communication (such as newsletters, e-mail updates, Intranet);
face-to-face communication in meetings, physicians’ offices or lounges
Distribute key messages using a multi-modal methodology
5. Using Physicians to Influence Change
Using the influence of key physicians and physician groups is another strategy that may
increase physician involvement in Appropriateness of Care improvements. Table 1
below provides a list of key physician groups within health care organizations that may
be used as a reference when implementing Appropriateness of Care projects. The table
provides a suggested chronological order to approach various physician groups based
on level of hierarchy or influence and their roles and responsibilities for making
decisions within their organization:
Required Approval: includes those who must provide approval for
recommendations/actions;
Required Support: includes those who don’t have authority but should be
consulted to get their support;
Required Leadership/Steering: includes those who provide oversight and
directions to the project team;
Active Involvement: includes those who are actively involved in the project,
make recommendations, and act on the actions; and
Informed: includes those who must be informed when a decision is made or
work is completed.
Appendix B: Physician Involvement Strategy
Appropriateness of Care Framework 33 Version 1: December 4, 2015
Table 1
Physician
Engagement Driver
Chronological
Order for
Support
Required
Approval
Required
Support
Required
Leadership/
Steering
Active Involvement
Informed
Senior Medical
Officers
1
Medical Department
Heads
2
Medical
Division/Section
Heads
3
Service Line Clinical
Experts/Physician
Leaders
3
Key Physician
Champions
4
Informal Physician
Leaders
5
Development Team
members
5
Saskatchewan
Medical Association
6
MD Residents 7
College of Medicine 8
College of Physicians
and Surgeons
8
SIPPA 8
Appendix B: Physician Involvement Strategy
Appropriateness of Care Framework 34 Version 1: December 4, 2015
References
Baker, Dr. Ross et al. Exploring the Dynamics of Physician Engagement and Leadership for
Health System Improvements: Prospects for Canadian Healthcare Systems Final Report. April
2013
Boiteau, Dr. Paul. Laporta, Dr. Denny. Engaging Physicians in your hospital Quality and
Safety Initiatives: for Senior Leaders (no year quoted on presentation)
Dickson, Graham. Anchoring Physician Engagement in Vision and Values: Principles and
Framework. Written for the Regina Qu’Appelle Health Region. 2012
Doctors of British Columbia. Policy Paper: Partnering with Physicians. January, 2012
Hayes, Dr. Chris W. A Physician’s Perspective on Quality and Patient Safety. Canadian
Patient Safety Institute. June 12, 2009
Kaissi, Amer. A Roadmap for Trust: Enhancing Physician Engagement. Written for the
Regina Qu’Appelle Health Region. 2012
Knowling Jr RE. Leading with Vision, Strategy and Values. Chap 15 in Leading for
Innovation and Organizing for Results. 2010
Marsden, Julian et al. Improving Care for British Columbians: The Critical Role for Physician
Engagement. Health Care Quarterly (Special Issue) December 2012
Reinertsen, J et al. Institute for Healthcare Improvement Innovation Series: Seven Leadership
Leverage Points for Organization Level Improvement in Health Care. Innovation Series White
Paper. 2005
Reinertsen Dr. J. et al. Institute for Healthcare Improvement Framework for Engaging
Physicians in a Shared Quality Agenda. Innovation Series White Paper. 2007
Sutker, William L. The Physician’s Role in Patient Safety: What’s in it for me? Baylor
University Medical Center Proceedings 2008 January; 21(1): 9–14.
Appropriateness of Care Framework 35 Version 1: December 4, 2015
Appendix C: Stakeholder Involvement Strategy: Patients, Families, Public and
Health System
Appropriateness of Care: Better Care Made Easier
Appropriateness of Care Framework: Stakeholder Involvement Strategy
Appendix C: Stakeholder Involvement Strategy
Appropriateness of Care Framework 36 Version 1: December 4, 2015
Stakeholder Involvement Strategy:
Patients, Families, Public and Health System
1. Introduction
As well as support and commitment from the larger health care system and physicians,
it is important to involve patients, their families and the public in improving
Appropriateness of Care. It’s critical to educate and engage patients so that they can
make informed choices about their care: help patients learn about the tests, treatments
or procedures in question, when they are necessary and when they are not, and what
they can do to improve their health. .
As part of the framework, this engagement plan provides key messages as well as
specific strategies for involving health system leaders, patients and families, and the
public in improving Appropriateness of Care.
2. Strategic Considerations
The Saskatchewan health system has embarked on a fundamental cultural
transformation, shifting from a process-driven system to one that is driven by the
health needs of patients. There are inevitable challenges in overcoming resistance
to changing the way things are done.
Communication, collaboration and commitment are needed to achieve a more
patient- and family-centered system.
Change fatigue is a risk, particularly with people who are tackling multiple
changes at once, or who feel they have no say in how the changes are
implemented.
The shift to a culture that fully supports clinicians in improving Appropriateness
of Care will take several years to accomplish.
Early adopters of new methods will need to forge ahead, without waiting for
everyone to buy into all aspects of the change.
When research, discussion and consensus-building fail to result in meaningful
change, incentives, disincentives and policy change may be needed to achieve
changes in behavior.
3. Key Messages to Communicate with Stakeholders about Appropriateness of
Care
Appropriateness of Care is a fundamental component of health care quality. The
issues around Appropriateness of Care were raised in the Patient First Review,
For Patients’ Sake, released in October 2009. According to this report, patients
Appendix C: Stakeholder Involvement Strategy
Appropriateness of Care Framework 37 Version 1: December 4, 2015
with the same health issues often receive very different care, depending on
where they live.
Overuse, underuse, misuse and variation in healthcare services are
characteristics of inappropriate care. For example, unnecessary diagnostic
testing and treatments may expose patients to potential harm or negative
outcomes, and increase wait times for those patients who truly need to access
these necessary testing and treatments.
The Saskatchewan health system has committed to improving Appropriateness
of Care through working collaboratively with physicians, other healthcare
professionals, patients and researchers in embedding the Appropriateness of
Care framework into the system.
The intention of providing a framework for Appropriateness of Care is to
provide a strategy for the healthcare system, ultimately ensuring that all patients
in Saskatchewan receive “The right care provided by the right providers, to the right
patient, in the right place, at the right time, resulting in optimal quality care.”23
4. Involving Health System Leadership and Providers
Health system leadership support is critical for the success of the Appropriateness of
Care program as they are important decision makers within the system. Although the
Provincial Leadership Team (PLT)24 has endorsed Appropriateness of Care program
through the Health System Strategic Planning process (Hoshin Kanri), there is still a
perception of lack of urgency and uncertainty in the financial commitment required for
broad implementation of the framework. Other healthcare clinicians (nurses,
pharmacists, physiotherapists, dietitians, etc.) and the research community, such as the
Saskatchewan Center for Patient Oriented Research (SCPOR) are also important
stakeholders as they are important providers to patient care and need to be involved in
Appropriateness of Care. The driver diagram in Figure 1 below illustrates the goal, key
drivers and the actions to engage health system leadership and providers.
Goal: to create an environment where health care providers are supported to
implement the Appropriateness of Care framework within their organizations and
practices.
23
Canadian Medical Association 2013 24
PLT is comprised of the Ministry of Health Deputy Minister’s Office, CEOs of health regions, Saskatchewan Cancer Agency (SCA), eHealth, and 3sHealth, Board Chairs, and physician representatives. They are the decision makers of the Saskatchewan health system.
Appendix C: Stakeholder Involvement Strategy
Appropriateness of Care Framework 38 Version 1: December 4, 2015
Key Drivers and Actions:
Involve health system senior leadership in governance and decision making.
Currently, several CEOs of health regions and healthcare organizations are
sponsors of the Appropriateness of Care program and are accountable for the
framework development and implementation.
Increase awareness and understanding of Appropriateness of Care issues
(overuse, underuse and misuse of healthcare services) and the work that is
currently underway (i.e. the Provincial Appropriateness of Care program and
the provincial framework)
Increasing awareness of Appropriateness of Care through a series of
presentations to key stakeholders was started in late 2014-15. The series
presentations kicked off at the Ministry of Health Senior Leadership Team
meeting to obtain the Ministry’s endorsement of the provincial
Appropriateness of Care program.
Creating awareness of Appropriateness of Care will continue throughout
2015-16 to engage RHAs, and other health care organizations, soliciting their
support and willingness to implement the framework in their organizations.
Create collaborative partnerships with health regions, Saskatchewan Cancer
Agency (SCA), eHealth, 3sHealth and the academic research community
Success of the Appropriateness of Care framework will require a support
structure at the local organizational level that will facilitate health regions, the
SCA and other healthcare organizations within the system to undertake their
own Appropriateness of Care projects. The provincial Appropriateness of
Care project team was established to develop the Appropriateness of Care
framework and implement provincial Appropriateness of Care projects. This
team will provide support to health regions or healthcare organizations
interested in developing their own support structure to initiate
Appropriateness of Care. This will include advice, tools, and education and
training to clinicians and quality improvement staff about the framework and
methodologies, etc.
The Canadian Institute of Health Research (CIHR) launched a nation-wide
strategy for improving the patient oriented research (POR) capacity in
Canada. Saskatchewan stakeholders have been working on developing a
business plan that will be submitted to CIHI in June, 2015 to implement a
POR strategy in Saskatchewan. The SCPOR group is comprised of
researchers and academic research organizations (University of
Saskatchewan, University of Regina, First Nations University, Saskatchewan
Appendix C: Stakeholder Involvement Strategy
Appropriateness of Care Framework 39 Version 1: December 4, 2015
Polytechnic, and HQC). They have identified Appropriateness of Care as
their initial priority. SCPOR will work collaboratively with the provincial
Appropriateness of Care project team as well as regional Appropriateness of
Care programs to provide research support required for Appropriateness of
Care projects, including: literature review on best practices; clinical guidelines
and tools; development of data; and evaluating the impact of the project in
improving patient experiences and outcomes.
Various communication mechanisms and tools (e.g. electronic newsletter,
website, will be developed to communicate with health system partners
about the progress of improving Appropriateness of Care and to share
success stories and lessons learned from projects.
Inform health system Leadership about the progress in implementing the
Appropriateness of Care framework and the success stories so that they can
provide continued support for improving Appropriateness of Care.
Performance measures as well as success stories will be reported to PLT on a
quarterly basis and to the Ministry of Health Senior Leadership Team (SLT)
on a monthly basis.
Appendix C: Stakeholder Involvement Strategy
Appropriateness of Care Framework 40 Version 1: December 4, 2015
Figure 1: Involving Health System Leadership and Providers
Create Partnerships with Health Regions, SCA, eHealth, 3sHealth &
Academic Research Community
Increase Health System Awareness of AC related Issues and Work
Inform Health System Leadership about Progress and Successes
Involve Health System Senior Leaders in Governance and Decision Making
HEALTH SYSTEM ENGAGEMENT GOAL KEY DRIVERS ACTIONS
Involve Health System Senior Leaders (e.g. CEOs, SMOs) in the AC Steering Committee
Appropriateness of Care Awareness Campaign (Roadshows) to inform health regions, SCA, eHealth and 3sHealth about the AC
framework and its implementation plan
Meet RHAs/SCA CEOs, SLTs, and board members to get their commitment and support for moving forward with AC
Help RHAs/SCA set up a QI structure for implementing the AC projects within their own organization
Create mechanisms and communication tools to share success stories and lessons learned across the system
Provide progress updates at the PLT Wall Walks and the Ministry of Health SLT Wall Walks
Create a collaborative partnership with researchers and the academic research organizations to integrate research
component into implementing and evaluating AC projects
To create a supportive environment where clinicians and other healthcare professionals are
motivated to implement the Appropriateness of Care (AC) Framework within their own
organization and practices
5. Involving Patients, Families and the Public
“I believe that when patients are given the information and the opportunity, we will
become better partners with our Healthcare providers regarding appropriate testing
(better partners in all aspects of our care). I think most patients and families want our
healthcare providers to know that when we are asking questions......it is not to challenge
them.....but only to understand….We can begin to make good, informed decisions "with"
our doctors, rather than having decisions made "for" us.”
- Cindy Dumba, a Patient and Family Advisor
Appendix C: Stakeholder Involvement Strategy
Appropriateness of Care Framework 41 Version 1: December 4, 2015
Acknowledging that patients and families are not only the recipients of healthcare
services but also should be important partners in improving quality and safety of
healthcare services, the Saskatchewan health system has committed to achieving
Patient- and Family-Centered Care (PFCC) by making PFCC one of the foundations for
achieving its strategic goals. Many health regions and organizations have already
established a structure to engage patients and families in quality improvement work,
and have been actively involving them using Lean strategies and tools (e.g. Rapid
Process Improvement Workshops, Value Stream Mapping, 3P events) and other
strategic initiatives. This is significant progress for the Saskatchewan health system,
however, there is more work to be done in involving patients and their families in their
care and treatment decision making. In order for them to be involved in their own care,
they need to be fully informed about their diagnosis, treatment options, risks and
benefits of each option.
Many patients often conduct their own research and consult their social networks
(Frosch et al, 2012) and use Internet-based resources to supplement the information they
receive from their physicians. The quality of information obtained from the Internet,
however, tends to be poor as they often lack scientific, evidence based information
(Griffiths and Christensen, 2000; Kisely et al, 2003). This can potentially provide
patients with misleading information and demand for unnecessary treatments.
There is an argument that patient demand for certain diagnostic testing or treatment
can lead to inappropriate care. For example, availability of advanced medical
technology has contributed to increased patient demand for unnecessary diagnostic and
screening tests that may provide no values to their treatment and can potentially lead to
early detection of diseases resulting in over-diagnosis and over-treatment.
Some argue that physicians’ opinions or personal beliefs may influence patient’s
decision on their treatments (Wright et al, 1999; Bederman et al, 2011; Fowler et al, 2000;
Pearce et al, 2008). Not all clinicians agree on the best treatment option for a patient
with a particular condition when more than one treatment option is available. This may
result in clinical practice variation. Advocates for patient and family involvement in
their treatment decision making argue that informing and involving patients in the
decision making process may potentially reduce not only patient demand for
unnecessary healthcare services but also clinical practice variation.
Current healthcare culture is not entirely supportive of patient involvement in the
decision process. Some of the barriers include:
The current clinician payment structure (fee for service) makes it difficult for
physicians to involve patients in treatment decision making due to time
constraints. Physicians may need more consultation time to fully involve patients
in treatment decision making. The average primary care visit is 15 minutes, and
Appendix C: Stakeholder Involvement Strategy
Appropriateness of Care Framework 42 Version 1: December 4, 2015
during this time, the clinician often has to take a history, perform a physical
examination, make a diagnosis, review concerns and write a prescription.
Providing detailed information on treatment options and eliciting patient’s
values and preferences for treatment choice on top of their routine exam may
take more than 15 minutes.
Not all patients understand medical terminology and the resulting risks
presented by their physicians. Studies suggest that there are a few ways to
communicate effectively with patients about risks associated with treatment
choices. There is evidence that graphics, pictures and visual metaphors are
better understood by patients with low health literacy (Gigerenzer et al, 2008;
Houts et al).
Some patients may have the fear of being assertive. Patients may feel that
questioning their physician’s advice might be seen as challenging their authority,
which may threaten the future of their relationship with the physician as well as
the care they receive.
Some of these barriers to involve patients in treatment decision making will be
addressed through Shared Decision-Making (SDM), a collaborative decision making
process shared between patients and their clinicians to make mutually agreed upon
healthcare decisions using evidence-based information, patient’s needs, values,
preferences, and cultural/religious beliefs and background (see the SDM Toolkit for
more detailed information on SDM).
The goal, key drivers, and the actions to increase patients/families/the public
involvement in improving Appropriateness of Care are:
Goal: To create a collaborative partnership with patients and families in improving
Appropriateness of Care.
Key Drivers and Actions:
Involve patients and families in the governance and decision making process
Two Patient and Family Advisors are currently involved in the
Appropriateness of Care Steering Committee, providing strategic direction
and oversight to the provincial Appropriateness of Care program.
A process for gathering patients’ voices and perspectives on selecting clinical
areas of focus for Appropriateness of Care projects will be developed and
implemented.
Appendix C: Stakeholder Involvement Strategy
Appropriateness of Care Framework 43 Version 1: December 4, 2015
Involve patients and families in implementing the Appropriateness of Care
framework
Patient and Family Advisors will be involved in designing and implementing
Appropriateness of Care projects to ensure that the process and outcomes
meet the needs of patients rather than the needs of providers.
Two PFAs are currently being involved in the MRI of Lower Back Pain
project as part of the project development team comprised of mainly
clinicians (orthopedic surgeons, neurosurgeons, radiologists, and family
physicians) and a few researchers.
Patient stories will be used to increase awareness of Appropriateness of Care
as well as get buy-in and support from various stakeholder groups, including
health system leaders, clinicians and other providers. They are powerful
tools for communicating why the system needs to address issues related to
Appropriateness of Care.
Ideally and if possible, Appropriateness of Care projects will use patient
reported outcomes measures (PROMs) to assess the impact of the projects in
patient outcomes. Patients and families will be involved in the process of
measuring these outcomes.
Involve patients in treatment decision making at the level they choose, so that
their values and preferences for treatment choices are incorporated into their
treatment plan (Shared Decision Making).
Shared Decision- Making process and tools will be embedded into
Appropriateness of Care projects. This will help patients understand the
information they received from their clinicians about their diagnosis and
treatment options as well as help clarify their values and preferences for the
treatment options (See the SDM Toolkit for further detailed information).
Increase patient/public awareness of potential harm associated with
unnecessary diagnostic testing and treatments
The Choosing Wisely Canada Campaign focuses on addressing issues related
to overuse of unnecessary treatments and diagnostic tests. This campaign
targets both physicians and patients and has been supported by the Canadian
Medical Association and the Saskatchewan Medical Association (SMA). The
provincial Appropriateness of Care program will work collaboratively with
SMA to leverage resources developed by the “Choosing Wisely Canada
Campaign” to publicly promote appropriate uses of various diagnostic
testing and treatments in Saskatchewan.
Appendix C: Stakeholder Involvement Strategy
Appropriateness of Care Framework 44 Version 1: December 4, 2015
Various communication tools will be developed to increase public awareness
of appropriate uses of healthcare services as well as of importance of patient
and family involvement in healthcare treatment decision making. Some of
the methods and tools may include a news release, a media launch,
presentations to Patient and Family Advisory Councils in health regions and
the SCA, public town hall meetings, posters in clinics and hospitals,
advertisements in newspapers and radios, use of social media to share
success stories.
Figure 2: Involving Patients, Families and the Public
To Create a Collaborative Partnership with Patients and
Families in Improving Appropriateness of Care (AC)
Involve Patients/Families in Treatment Decision Making (Informed/Shared
Decision Making)
Involve Patients/Families in Governance and Decision Making
PATIENT ENGAGEMENT GOAL KEY DRIVERS ACTIONS
Involve Patient and Family Advisors (PFAs) in the AC Steering Committee
Develop a process to hear patient voices for selecting the next AC projects and priority areas
Embed Shared Decision Making process and tools into AC projects
Provide clinicians with education/training/tools for involving patients in treatment decision making
Increase Patient/Public Awareness of AC related Issues
Awareness campaign (road shows) to Patient and Family Advisory Councils (PFACs) across the system
Work collaboratively with SMA to leverage patient education materials developed by “Choosing Wisely Campaign to promote
AC to the public
Develop communication tools to increase public awareness of AC (e.g. news releases, media launch, public town hall meetings,
posters in clinics and hospitals, social media advertisement)
Involve Patients/Families in Implementing the AC Framework
Involve PFAs in designing and implementing AC projects (members of the Project Development Teams)
Use patient stories to increase awareness of AC
Involve patients in measuring outcomes of AC projects (Patient Reported Outcomes)
Appendix C: Stakeholder Involvement Strategy
Appropriateness of Care Framework 45 Version 1: December 4, 2015
6. Feedback Loop and Evaluation
It is important to inform the stakeholders about the status of implementing the
Appropriateness of Care framework and to celebrate successes with them to reinforce
the culture change that is happening within the system as a result of this work. The
following tools may be used to inform and celebrate successes with the stakeholders:
Health System Leadership and Providers Patient, Families and Public
Electronic News Letters;
Quarterly Provincial Leadership Team
(PLT) Wall Walks
Monthly Ministry of Health Senior
Leadership Team Wall Walks
Appropriateness of Care Website TBD
Social Media to share success stories
Appropriateness of Care Website
News Releases
It is also important to evaluate the effectiveness of the stakeholder engagement process.
Tools for evaluating the engagement process may include surveys to stakeholders,
particularly clinicians about their awareness of the Appropriateness of Care work and
to identify any culture shift among these groups on their perceptions or perspectives of
Appropriateness of Care.
7. Multi-year Action Plan
In order to successfully achieve the engagement goals, actions have been prioritized
over the next three years. This doesn’t mean that the Appropriateness of Care program
will be done at the end of the third fiscal year- improving Appropriateness of Care
within the system requires a transformation that will continuously evolve over time.
The work over the first three years will be foundational and help create an environment
where Appropriateness of Care becomes a norm within the Saskatchewan health
system in the future.
Phase 1 (2015-16)
Focus on increasing stakeholders’ support for the provincial Appropriateness of
Care program and implementation of the Appropriateness of Care framework as
well as identify their expectations about the provincial program (i.e. Awareness
Campaign)
Create a collaborative partnership with research communities (i.e. SCPOR) to
embed research components into improving Appropriateness of Care
Continue to inform PLT and other key stakeholders about the progress of
implementing the framework
Appendix C: Stakeholder Involvement Strategy
Appropriateness of Care Framework 46 Version 1: December 4, 2015
Continue to involve Patient and Family Advisors in the Appropriateness of Care
Governance and the MRI of Lumbar Spine project.
Provide support to RHAs, SCA and other healthcare organizations in creating
regional Appropriateness of Care programs within their own organization to
initiate Appropriateness of Care projects
Develop communication tools for sharing the Appropriateness of Care
framework, toolkits, progress update on implementing the framework, and other
information with health system stakeholders
Develop and implement tools to evaluate stakeholder engagement (e.g. surveys)
Align work with the SMA and Choosing Wisely Canada campaign.
Phase 2 (2016-17)
Launch the public awareness campaign to educate the public about
Appropriateness of Care issues (particularly uses of unnecessary diagnostic
testing, treatments and screening), what is appropriate care, and how to get
involved in their own care and decision making. The public awareness
campaign will be aligned with the Choosing Wisely Canada Campaign to ensure
that the public receives the consistent information.
Develop Shared Decision Making (SDM) tools and embed them into
Appropriateness of Care projects where applicable.
Develop SDM educational tools for clinicians and embed them into the
Appropriateness of Care clinician education program that will be developed to
train clinicians on Appropriateness of Care and its methodologies and tools.
This program will be embedded into the medical school curriculum and the
Continuing Medical Education (CME) program.
Continue to provide support to RHAs, SCA and other healthcare organizations
in initiating Appropriateness of Care projects within their own organizations.
Continue to embed SDM tools into Appropriateness of Care projects where
applicable
Evaluate the stakeholder evaluation plan and communication tools to measure
the level of stakeholder engagement and the effectiveness of the plan (e.g.
surveys)
Appendix C: Stakeholder Involvement Strategy
Appropriateness of Care Framework 47 Version 1: December 4, 2015
Phase 3 (2017-18)
Continue the public awareness campaign
Continue to provide support to RHAs, SCA and other healthcare organizations
in implementing Appropriateness of Care projects within their own
organizations
Evaluate the stakeholder engagement plan to measure the effectiveness and
outcomes of the plan (e.g. surveys)
Keep momentum going through sharing the lessons learned from
Appropriateness of Care projects and celebrate the successes with stakeholders
Sustain improvements that have been made over the last three years
Appendix C: Stakeholder Involvement Strategy
Appropriateness of Care Framework 48 Version 1: December 4, 2015
References:
Bederman SS, Coyte PC, Kreder HJ, Mahomed NN, Mclsaac WJ and Wright JG. Who’s
in the Driver Seat? The Influence of Patient and Physician Enthusiasm on Regional Variation
in Degenerative Lumbar Spinal Surgery: A Population-based Study. 2011. Journal of Spine.
Mar15; 36(6): 481-489.
Fowler FJ, McNaughton CM, Albertsen PC, Zietman A, Elliott DB and Barry MJ.
Comparison of Recommendations by Urologists and Radiation Oncologists for Treatment of
Clinically Localized Prostate Cancer. 2000. JAMA 283(24):3217-3222
Frosch DL, May SG, Rendle KAS, Tietbohl C and Elwyn G. Authoritarian Physicians and
Patients’ Fear of Being Labeled ‘Difficult’ Among Key Obstacles to Shared Decision Making.
2012. Health Affairs 31(5): 1030-1038
Griffiths K M and Christensen H. Quality of Web Based Information on Treatment of
Depression: Cross Sectional Survey. 2000. BMJ December 16; 321(7275): 1511-1515.
Kisely S, Ong G, and Takyar A. A Survey of the Quality of Web Based Information on the
Treatment of Schizophrenia and Attention Deficit Hyperactivity Disorder. 2003. Aust N Z J
Psychiatry. 37(1):85-91
Moynihan R, Doust J and Henry D. Preventing Overdiagnosis: How to Stop Harming the
Healthy. 2012. BMJ volume 344
Pearce A, Newcomb C and Husain S. Recommendations by Canadian Oncologists and
Radiation Oncologists for the Treatment of Clinically Localized Prostate Cancer. 2008.
Canadian Urological Association Journal 2(3): 197-203.
Wright JG, Hawker GA, Bombardier C, Croxford R, Dittus RS, Freund DA and Coyte
PC. Physician Enthusiasm as an Explanation for Area Variation in the Utilization of Knee
Replacement Surgery. 1999. Med Care. Sept; 37(9): 946-56.
Appropriateness of Care Framework 49 Version 1: December 4, 2015
Appendix D: Data and Measurement Strategy
Appropriateness of Care: Better Care Made Easier
Appropriateness of Care Framework: Data and Measurement Strategy
Appendix D: Data and Measurement Strategy
Appropriateness of Care Framework 50 Version 1: December 4, 2015
Data and Measurement Strategy
1. Introduction
Successful implementation of the provincial Appropriateness of Care framework is
dependent on the availability of relevant clinical information to support continuous
learning and improvement. Throughout this work timely and accurate data is
necessary for context and evaluation as clinical groups question appropriateness of care,
consider their patient outcomes and processes, identify areas of variation, and
implement change.
It is recognized that without valuable clinical information it will not be possible to
understand the current state nor will it be possible to understand the impact of any
practice changes to patient outcomes and appropriateness of care. The development of
valuable clinical information systems requires leadership, methodology, and human
resource and infrastructure support.
Saskatchewan has rich health databases for use in quality improvement and clinical
research. There are a number of databases that are frequently utilized and have strong
structures in place for data access and analysis (e.g. Discharge Abstract Database, MDS,
etc.). However, in other instances databases exist that are not widely known and
increased awareness of their existence could support clinical quality improvement. Still,
in other situations, the necessary clinical data to support specific projects may not exist
and new data systems are needed. Human resources and sound processes are required
to support the awareness, access and development of data systems. Additionally, there
are multiple organizations in Saskatchewan involved in various aspects of data system
development and reporting and for the Appropriateness of Care program to best
support clinicians with valuable information it is important that the roles and
responsibilities of these various organizations are identified.
The Appropriateness of Care program team has developed a Driver Diagram (Figure 1)
to outline the key drivers and actions that exist in the Saskatchewan health system, or
are required, to support this work and achieving the goal of “clinicians will have
valuable information to support continuous learning and improvement.”
2. Drivers of Strong Data Systems
The goal, primary drivers, and actions to create a strong clinical information system for
Appropriateness of Care are:
Appendix D: Data and Measurement Strategy
Appropriateness of Care Framework 51 Version 1: December 4, 2015
Goal: Clinicians will have valuable information to support continuous learning and
improvement
Primary Drivers and Actions:
Figure 1: Creating a Strong Clinical Information System
Increase Awareness and Accessibility of Data: Data access includes awareness
of available data in Saskatchewan and ability to access and use this information.
eHealth Saskatchewan is currently creating a meta data catalogue that will
provide a comprehensive review of all databases in Saskatchewan. It will
allow users to know what data is available and how it can be used.
Appendix D: Data and Measurement Strategy
Appropriateness of Care Framework 52 Version 1: December 4, 2015
Additionally they are working on a data warehouse and data mart structure
that will facilitate ease of access to many databases and linkage between
multiple databases. They have proposed modifications to their data
warehouse governance structure which would result in more timely access to
data.
Data access includes the logistics of obtaining data from existing datasets, and
obtaining new data to create new datasets. Clear processes are required for
when and how data sharing schedules, ethics agreements and patient consent
are required. These processes will be different depending on:
o Whether the data/database exists or whether creating a new database is
proposed and; and
o If the required database does exist, whether it is located within a
centralized data warehouse or is an independent database within a health
organization.
Human Resource and Infrastructure Capacity for Measurement System
Design:
Human resource capacity is required for facilitation support for measurement
system design. This includes the identification of metrics, the required data to
report metrics, and data collection and reporting strategies. This facilitation
also includes support for using metrics to drive continuous learning and
quality improvement.
The key guiding principles of the measurement system design include:
o Organizing data flow around value-added (front line) work processes,
o Using data for patient care (disease management) but also for rolling it up
for reporting and accountability at the level of individual health
professionals, facilities/clinics/practice groups, hospitals, regions, and at
the provincial and national level.
o It is important that the right data is collected once, at the point of origin
and then used for all applications.
o All value-adding work is inherently local. All improvement is inherently
local; therefore, implementation of a data collection system can't destroy
clinical productivity. Instead, data collection must be integrated into
workflow at the front line
The role of the provincial Appropriateness of Care team is to both provide
facilitation and support as well as to build capacity within the Saskatchewan
health system to lead this work. They have developed a data methodology
Appendix D: Data and Measurement Strategy
Appropriateness of Care Framework 53 Version 1: December 4, 2015
document within the Appropriateness of Care tool kit to further support the
development of measurement systems within clinical projects (See Toolkit 4).
Additionally, human resource capacity is required to support the data
collection, data entry and analysis once the measurement system is designed
and implemented.
Finally, system support and infrastructure is necessary to support
implementation of new data systems. Electronic infrastructure is an
important component of measurement system design. This will include
identification of how the measurement system may fit into current electronic
infrastructure or if a new electronic infrastructure will be created, and within
what timelines.
Strong partnerships between the Appropriateness of Care team and eHealth
will be necessary to facilitate modifications of existing and development of
new electronic infrastructure.
Data Governance
The Appropriateness of Care data strategy will be overseen by the
Appropriateness of Care governance structure (see Appendix E) but will be
strongly influenced by the Saskatchewan data environment including other
governance organizations such as the eHealth Information Advisory
Committee and the eHealth Information & Analytics Sub-Committee.
When selecting Appropriateness of Care provincial projects, or providing
support to regional Appropriateness of Care projects it will be important to
consider the necessary and available data to support such work.
Additionally, a key role of the Appropriateness of Care teams will be to
garner support for the provincial development of data systems that will
impact the Appropriateness of Care work.
As it relates to the data strategy the Appropriateness of Care governance will
approve the overall data strategy and data collection and reporting plan
within clinical areas of focus and approve allocation of resources to carry out
the plan(s).
There are multiple health organizations in Saskatchewan with capacity and
capability to provide clinical information support to clinical groups. For the
Appendix D: Data and Measurement Strategy
Appropriateness of Care Framework 54 Version 1: December 4, 2015
Appropriateness of Care program to best support clinicians with valuable
information it is important that the roles and responsibilities of these various
organizations are identified. Suggested roles for these organizations include:
o Health Quality Council
Assist in identifying existing data and data reports to support early
project work.
Collaborate with other partners and clinical development teams to:
- Develop clinical process maps;
- Define metrics needed for learning and improvement and how they
will be reported;
- Define data elements and collection methods;
- Facilitate development of database design, data entry and analytics
for paper based data systems; and
- Assist in building capacity and capability for RHAs and providers
to independently collect, enter, and analyze data.
- Create capacity and skills for measurement and analysis for quality
improvement and new knowledge generation
o Ministry of Health
Assist with identifying and creating data reports for databases that the
MoH has access to.
Assist in facilitation of data access.
o eHealth Saskatchewan
Assist with identifying existing datasets and linkage between
databases.
Assist in facilitation of data access.
Collaborate with other partners to create electronic platforms for new
data capture, analytics, and reporting.
Assist in building capacity and capability for RHAs and providers to
independently collect, enter, and analyze data.
o Regional Health Authorities
Assist in identifying existing data from relevant datasets.
Assist in facilitation of data access.
o Saskatchewan Cancer Agency
Assist in identifying existing data from relevant datasets.
Assist in facilitation of data access.
Appendix D: Data and Measurement Strategy
Appropriateness of Care Framework 55 Version 1: December 4, 2015
o Saskatchewan Health Information Analyst Network
Assist in identifying existing data from relevant datasets.
Assist in analytics
o Saskatchewan Centre for Patient Oriented Research
Provide access to data platforms developed for research and learning
related to health system priorities.
Collaborate with steering committees for health system priorities (of
which appropriateness may be part) to develop shared research
priorities.
Conduct research studies as defined in the SCPOR strategic plan.
(Directly related to health system priorities of which appropriateness
may be part)
Share the results of relevant research projects.
Create capacity in collaboration with system partners including
measurement, analysis and research.
Budgetary responsibilities for measurement system design may be spread across
multiple organizations. Many activities carried out under the strategy would be
accomplished by in-kind allocation of staff time and data capture and analytics
development resources from participating organizations.
Additional funding may be required to acquire new software and/or hardware
for data capture, analytics, and reporting. Planning and approval for these
acquisitions would occur through the Provincial Leadership Team/Central
Government strategic planning and budgeting process.
3. Key Messages Regarding Appropriateness of Care and Data Strategy
The Saskatchewan health system has committed to improving Appropriateness
of Care through working collaboratively with our physicians, other healthcare
professionals, patients and researchers in embedding the Appropriateness of
Care framework into the system.
Implementation of this program requires that clinicians have access to valuable
information to drive continuous learning and quality improvement.
In order to provide valuable information to clinical groups the Saskatchewan
health system requires increased awareness of existing data, sound processes to
support data sharing, and human resource support to develop new measurement
systems.
Appendix D: Data and Measurement Strategy
Appropriateness of Care Framework 56 Version 1: December 4, 2015
The role of the Appropriateness or Care team is to both provide these tasks and
build capacity within the health system to take on this work.
Data governance and collaboration between multiple organizations is also
required.
Appropriateness of Care Framework 57 Version 1: December 4, 2015
Appendix E: Provincial Appropriateness of Care Program Governance Structure
Deputy Minister’s Office (DMO)
Provincial Leadership Team (PLT)
Appropriateness of Care Steering Committee
Provincial Appropriateness of Care Program Team
MoH SLT
eHealth
SCPOR
PKPO
Provincial Appropriateness of Care Network
Clinical Development
Teams
Provincial AC Projects
Clinical Development
Teams
Regional AC Projects
Regional AC Program
Regional AC Program
Regional AC Program
Regional AC Program
Regional AC Projects
Regional AC Projects
Regional AC Projects
Clinical Development
Teams
Clinical Development
Teams
Clinical Development
Teams
PFCC Guiding Coalition
3sHealth
Appendix E: Provincial Appropriateness of Care Program Governance Structure
Appropriateness of Care Framework 58 Version 1: December 4, 2015
Roles and Responsibilities
Individual/Group Major Responsibilities
Deputy Minister’s Office (DMO)
Ensure that the provincial AC program has adequate resources to achieve deliverables within the targeted timelines
Have decision-making authority and final approval on budget related to the Appropriateness of Care (AC) work including the provincial AC program, the provincial AC Network and AC projects
Provincial Leadership Team (PLT)
Provide advice and approval on the outcome and improvement targets as well as AC program deliverables
Provide operational support where able for the implementation of provincial AC projects
Identify or recommend clinical areas of focus for selecting provincial AC projects
Help to remove barriers to success of the program.
Appropriateness of Care Steering Committee
Provide strategic direction and oversight of the program and projects
Has overall decision-making authority and approval of the AC strategic plan and project deliverables (i.e. A3s, business cases, PLT wall walk charts etc.)
Maintains the Ministry, PLT and RHAs support for AC work including the provincial AC program, the AC Network and provincial AC projects
Report to PLT on the progress of AC work (Project Sponsor)
Monitor the progress of the project and provide advice and guidance on any issues and concerns related to the project performance
Be champions of AC work
Work with PLT members and other stakeholders to remove any challenges and barriers to implementing the provincial AC framework and provincial AC projects
Appendix E: Provincial Appropriateness of Care Program Governance Structure
Appropriateness of Care Framework 59 Version 1: December 4, 2015
Individual/Group Major Responsibilities
Provincial Appropriateness of Care Program Team
Provide recommendations to the AC Steering Committee
Monitor and measure the progress and outcomes
Provide update on the progress to the Steering Committee on a regular basis (e.g. quarterly update)
Develop program and project budgets, manage resources, and resolve program and project issues
Identify and engage supporting partners at the Ministry of Health, PKPO, KPOs/KOTs and other healthcare organizations (e.g. RHAs, SCA, HQC, affiliates, regulatory bodies, unions, educational institutions, SMA, etc.) in achieving project deliverables
Work collaboratively with supporting partners (MoH, SCPOR, eHealth, 3sHealth, RHAs, SCA) and stakeholders (SMA, regulatory bodies, healthcare educational institutions, etc.) to integrate and coordinate all AC efforts across the system
Give advisory support as able to RHAs/SCA and other health organizations regarding their AC programs (e.g. provide facilitation, consultation, data support, and education and training)
Lead, coordinate, replicate provincial AC projects
Communication and involvement around AC (e.g. stakeholder engagement, public awareness campaign, communication, etc.)
Align AC work with provincial priorities and initiatives
Support the provincial AC Network
Provincial Appropriateness of Care Network
Share information on regional progress on all of their AC work, innovative ideas, success stories, and lessons learned
Reduce any duplication by coordinating AC efforts across the system
Provide suggestions on provincial AC priorities for
Provide an implementation conduit to Regions in provincial AC projects
Encourage health regions and organizations use the common AC Framework methodology for improving AC
Use common indicators where being able to measure the provincial AC outcome and improvement targets
Appendix E: Provincial Appropriateness of Care Program Governance Structure
Appropriateness of Care Framework 60 Version 1: December 4, 2015
Individual/Group Major Responsibilities
Regional Appropriateness of Care Programs
Select targeted clinical areas for AC projects within their organization
Implement regional AC projects
Work collaboratively with other Regions, the provincial AC Team, and other organizations in order to achieve replication of AC projects
Monitor and measure progress and the outcomes
Provide ongoing communication with their senior leadership team (SLT) and those who will be impacted by their AC projects
Clinical Development Teams
Participate and develop agreed-upon best practice guidelines, tools and performance indicators for the AC projects
Be champions by communicating and promoting the importance of the project to their colleagues (Distributed Leadership Model)
Trial the project within their own regions (e.g. embedding the agreed best practices, tools and the data system into the clinical workflow)
Continuously improve the agreed-upon best practices and tools using the PDCA methodology
Share outcomes and lessons learned from the development and implementation of the project with others who may benefit from replicating it in their organization
Assist with monitoring, evaluation and auditing of an applicable project
Appropriateness of Care Framework 61 Version 1: December 4, 2015
Appropriateness of Care Framework: Toolkit
Appendix F: Appropriateness of Care Framework Toolkit
Appropriateness of Care: Better Care Made Easier
Appropriateness of Care Framework 62 Version 1: December 4, 2015
Appendix F: Appropriateness of Care Toolkit - Tool # 1
Implementation Process for Appropriateness of Care Methodology
Once the targeted clinical area of focus has been selected, the following implementation
steps may be applied to the project.
1. Establishment of a Clinical Development Team
Identify the physician and administrative lead who will support and oversee
the work
Identify key “clinical content expert” individuals (other physicians,
healthcare professionals, patients, researchers, etc.) who will be involved
Identify supporting resources (e.g. analyst support)
Identify roles, responsibilities, and time commitments required of members
Develop a communication strategy to engage development team members
(roles and responsibilities, remuneration etc.)
Begin to identify evidence based guidelines and literature that exists within
the clinical area of focus
Establish a timeline for establishing the development team
2. Identify improvement opportunities within the clinical area of focus
Map the current state for the selected process and identify areas where there
is variation or places for improvement exist
The Clinical Development Team prioritizes the project areas and considers
whether there is opportunity to address more than one project or agree on
one project
Set a timeline with an expected date for when the Clinical Development Team
should come to an agreement on what their project focus will be
Identify techniques for prioritizing projects if there is not a consensus within
the group
3. Establish common agreed practices, tools and data to measure the outcomes
and processes
Based on the current state, develop a common agreed practice or future state,
allowing for variation where data will be collected to further understand the
impact of such variation on patient outcomes
Appropriateness of Care Framework 63 Version 1: December 4, 2015
Discuss importance of measurement to support this work and determine
outcome, process and input measures. Include discussion on the importance
of Patient Reported Outcome Measures and Shared Decision-Making
4. Trial the common agreed practices and clinical support/data collection tools
Develop a plan for communication and engagement
Develop tools that can collect required data information, but that can be
integrated into the workflow and support clinical decision making
Identify the scope of the project, for example will this be trialed in one
practice group, city, one RHA, or the whole province etc.
Implement the agreed practice and tools and complete Plan, Do, Check,
Action (PDCA) cycles to understand effectiveness
5. Monitoring, evaluation and revisions
Develop a learning forum that will review the PDCAs, monitor outcome data
and provide reports back to the development team on the common agreed
practice. The forum will facilitate required revisions to tools, process,
common agreed practice etc.
Replicate to other clinical areas or to other organizations (e.g. facilities or
health regions to replicate the project)
In the new region, facility, or organization where replication is underway,
implement the common agree practice, tools, and data collection that were
developed in the implementation phase.
Continue to monitor, evaluate, and revise, data, tools and the common agreed
practice.
Appropriateness of Care Framework 64 Version 1: December 4, 2015
Appendix F: Appropriateness of Care Toolkit - Tool #2
Process and Criteria for Selecting Appropriateness of Care Projects
1. Identify potential clinical areas or opportunities for improving Appropriateness
of Care within your organization. You may consider the following information
when identifying potential areas:
Are there any improvement ideas generated by clinicians?
Are there high volume clinical processes/cases for which variation has been
identified by clinicians or the local system?
Are there Appropriateness of Care issues in the targeted regional and health
system priorities/hoshins/outcomes areas that need to be addressed?
What are the emerging healthcare issues at the regional, provincial and
national level?
Is there any new evidence from research that needs to be embedded into
clinical practices?
2. Identify key elements for the selection criteria that can be used for selecting
Appropriateness of Care projects for the coming year (s) (See the Table 1 for
suggested selection criteria)
3. Rank each element of the criteria on a scale of 1 - 5 (‘5’ being the highest and ‘1’
being the lowest) based on the level of importance and potential impact.
4. Assign the weighting scale to individual elements on a scale of 1 - 10 (‘10’ being
the highest and ‘1’ being the lowest) based on the relative importance (See the
suggested weights listed below in Table 1).
5. Calculate the scores of individual elements (multiplying the rank with the
weight) and then add them all to get the total score for an option.
6. Follow the same process to obtain the total scores for the other options and then
compare the scores of all the options to make a decision (See Table 2).
Appendix F: Appropriateness of Care Toolkit - Tool #2
Appropriateness of Care Framework 65 Version 1: December 4, 2015
Table 1: Selection Criteria for Appropriateness of Care Projects
Rank (1-5)
(5 being the
highest and 1
being the lowest)
Weighting Score
Impact on other health
regions/organizations (opportunities to
collaborate with other
regions/organizations)
Affects a significant portion of the patient
population that your organization serves
Aligned with health system
priorities/regional priorities (i.e. hoshins
and outcomes)
Potential for quick wins (easy to
implement)
Relatively low costs for implementation
(low investment)
Significant impact on quality of patient
care and safety
High cost, high volume
procedure/treatments or both
Ability to leverage existing structures to
support clinical change (e.g. provider
education/training and knowledge of QI
methodologies)
Administrative leadership (Senior
Leadership) support
Availability of clinician
leadership/champions
Evidence-based information/tools
available
Availability of data to identify issues and
measure the outcomes
Total Weighted Score
Appendix F: Appropriateness of Care Toolkit - Tool #2
Appropriateness of Care Framework 66 Version 1: December 4, 2015
Suggested Weights (Maximum Score: 320):
Impact on other health regions/organizations (opportunities to collaborate with
other regions and organization X 5
Affect a significant portion of patient population that your organization serves:
X 5
Aligned with health system/regional priorities (i.e. hoshins and outcomes) X 5
Potential for quick wins (easy to implement) X 2
Low cost of implementation (low investment) X 2
Significant impact on quality of patient care and safety X 10
High cost, high volume procedures/treatments or both X 5
Ability to leverage existing structures to support clinical change X 5
Administrative leadership (Senior Leadership) support X 5
Availability of clinician leadership/champions X 10
Evidence-based information/tools available X 5
Availability of data to identify issues and measure the outcomes X 5
Table 2: Total Weighted Scores for Individual Options
Option A Option B Option C Option D
Total Weighted Score
7. Once one or two clinical areas are selected, conduct an e-scan and literature
reviews to identify available best practices and tools, and what other
jurisdictions and organizations are doing to address inappropriate care issues in
the selected clinical areas
8. Develop business cases for the selected areas using the information collected
from the e-scan and literature reviews.
9. Obtain feedback on the business cases from committees or working groups that
are part of your organization’s Appropriateness of Care Governance and
Decision Making structure (e.g. the provincial Appropriateness of Care program
has the Appropriateness of Care Steering Committee that oversees the entire
program) – individual regions and organizations may have different Governance
and Decision Making structure for Appropriateness of Care.
10. Submit the business cases to appropriate the senior leadership team (SLT) within
your organization for their review and approval.
Appropriateness of Care Framework 67 Version 1: December 4, 2015
Appendix F: Appropriateness of Care Toolkit - Tool #3
Shared Decision-Making: Involving Patients and Families in Treatment
Decisions
What is Shared Decision-Making?
Shared Decision-Making (SDM) is a collaborative decision making process shared
between patients and their clinicians to make mutually agreed upon healthcare
decisions using evidence-based information, patient’s needs, values, preferences, and
cultural/religious beliefs and background. It requires a two-way information exchange
and deliberation between the two parties.
Does Shared Decision-Making Applicable to Any Care Conditions?
SDM is most appropriate for care conditions where there is more than one medically
reasonable treatment option (including status quo, “do nothing”) with no clear best
choice for outcomes. The treatment options for these conditions involve significant
tradeoffs in the patient’s quality or length of life. Many clinical situations, including
cancer care, elective surgery, screening, chronic disease conditions (life style change,
medication use), end of life care, mental health, etc., have more than one treatment
option. For such situations, the right choice will depend on a patient’s own needs,
preferences, and values supported by clinician’s recommendations or opinions.
Providing complete, evidence-based information about different treatment choices can
help patients make informed decision.
What are the Components of Shared Decision-Making?
A typical SDM process uses decision support tools designed to facilitate SDM by:
Providing patients with up-to-date, evidence-based information about their
condition and treatment options, including benefits, harms, outcome
probabilities and scientific uncertainties;
Helping patients clarify values and preferences they place on the benefits and
harms;
Guiding patients in deliberation to improve patient involvement in the decision
making process; and
Helping patients make an informed decision.
There are two types of decision support tools: Patient Decision Aids (PtDAs) and
Decision coaching/counseling. It is important to understand that decision support tools
are not to “replace” counseling from a clinician but to “complement” the clinician’s
counseling by helping patients prepare to engage in the decision making process and to
make informed, value-based decisions with their clinician. They are not intended to
advise patients to choose one option over another (IPDAS Collaboration)
Appendix F: Appropriateness of Care Toolkit - Tool #3
Appropriateness of Care Framework 68 Version 1: December 4, 2015
Patient Decision Aids (PtDAs)
There are numerous PtDAs developed in a variety of formats from a simple one-page
sheet that outlines treatment choices to more detailed pamphlets, booklets, computer
programs, DVDs or interactive websites that include filmed interviews with patients
and professionals. PtDAs are different from traditional patient information/education
materials and clinical guidelines in that they explicitly state what decision is to be made;
use the best available evidence to qualify benefits and harms; and help patients
deliberate about the options based on their values and preferences (Coulter & Collins,
2011; Deyo, 2001).
Decision Coaching
Decision coaching refers to the process by which a knowledgeable health professional
provides a patient with individualized, nondirective guidance to meet decision-making
needs in preparation for consultation with the clinician (Stacey et al, 2012). Decision
coaching is considered a useful adjunct to clinician counseling, especially when a
patient experiences decisional conflict - a state of uncertainty in identifying the best
course of action when a patient is confronted with decisions involving risk or
uncertainty of outcomes (O’Connor, 1995).
What does a Typical Shared Decision-Making Process Look Like?
The following steps have been identified in the inter-professional SDM (IP-SDM) model
developed by the Ottawa Hospital Research Institute. These steps maybe adapted for
the routine clinical practices in Saskatchewan.
1. Make it clear to the patient that a decision need to be made;
2. Exchange information about the options, benefits, and harms (PtDAs can be used
to provide this information. They can be provided during or after the
consultation);
3. Clarify patient’s values and preferences (there are questionnaires developed to
help clarify patients’ values and preferences);
4. Discuss feasibility of the options (e.g. accessibility and costs);
5. Arrive at mutually agreed upon decision (at this step, if the patient and/or
families are still not comfortable with decision making, he/she may delegate
decision making role to his/her clinician); and
6. Implement the chosen option (for chronic condition management, patients
and/or families may require guidance for implementing).
SDM conversations can be provided by any clinicians, including physicians, nurse
practitioners, and other healthcare professionals, depending on clinical settings.
However, one of the biggest perceived barriers identified by physicians to
implementing SDM was “time constraint”. For instance, an average physician-patient
Appendix F: Appropriateness of Care Toolkit - Tool #3
Appropriateness of Care Framework 69 Version 1: December 4, 2015
consultation time is 15 minutes. During this 15 minutes, physicians may have to do
multiple tasks, including taking a medical history from the patient, performing a
physical examination, making a diagnosis, reviewing concerns, writing a prescription,
etc. It can be challenging for physicians to be engaged in the full process of SDM.
To address this time constraint, some organizations or clinical practices have utilized
other healthcare professionals, such as nurses, dietitians, social workers,
physiotherapists, pharmacists or other appropriate practitioners to provide PtDAs and
decision coaching to the patients. In Saskatchewan, patients considering hip or knee
replacement surgery are referred to a multidisciplinary clinic where patients receive
PtDAs and decision coaching. The designated decision coach creates a decision
summary, including patient clinical condition, patient’s values and preferences. This
decision summary is forward to the surgeon to be used during the next consultation
with the patient.
Why Do We Want to Implement Shared Decision Making in Saskatchewan?
There has been a growing interest in SDM around the world as a means of delivering
the appropriate treatment to patients through information sharing and empowering
them to participate in their own care and decision making. However, there is a
significant gap between what patients want and what clinicians think they want in
terms of treatment. According to systemic researches conducted on SDM, patients
choose differently when they are fully informed about treatment options with their
benefits and risks (Stacey et al, 2011). A treatment decision is a function of both medical
diagnosis and preference diagnosis. Misdiagnoses of patients’ preferences and values
can affect not only health outcomes and wellbeing of patients but also costs of the
healthcare service delivery (Mulley et al, 2012). There is evidence suggesting that SDM
provides benefits not only to patients, but also to providers and the healthcare system:
For patients, SDM improves patients’ knowledge of treatment options,
satisfaction with the treatment choice and their adherence to their treatment
regimes.
For providers, SDM improves quality of consultation and increases trust in the
patient-clinician relationship without increasing consultation time.
For the system, SDM can potentially reduce unwarranted clinical variations and
ensure that the care patient received is appropriate (i.e. address overuse,
underuse, and misuse of healthcare services).
Appendix F: Appropriateness of Care Toolkit - Tool #3
Appropriateness of Care Framework 70 Version 1: December 4, 2015
What are the Potential Clinical Areas for Implementing Shared Decision Making?
As part of the Saskatchewan Surgical Initiative, SDM has been implemented in the
surgical pathways: hip and knee replacement, prostate cancer treatment, and treatment
of pelvic floor conditions.
SDM can be embedded into various other clinical areas within:
Cancer care;
Elective surgery;
Cancer screening (e.g. breast cancer, prostate cancer, colorectal cancer, etc.);
Chronic disease management (e.g. prescription medications);
Mental health (depression, anxiety, schizophrenia, etc.)
Pregnancy and Child Birth (e.g. prenatal testing, child birth, breastfeeding, etc.);
and
End of life care (place of care at the end of life - at home or at a facility,
treatments that prolong the life, long-term feeding tube placement for elderly
patients, planning care for critically ill patients in the Intensive Care Unit (ICU),
Cardiopulmonary Resuscitation (CPR), life support, artificial hydration and
nutrition, etc.)
Appendix F: Appropriateness of Care Toolkit - Tool #3
Appropriateness of Care Framework 71 Version 1: December 4, 2015
Roles of Patients and/or Families
Understand the information provided by their clinician (ask questions to the clinician if they don’t understand the information).
Share personal information about their life style, cultural backgrounds and beliefs, values, and preferences that may affect treatment decisions with their clinician.
Weigh their values and preferences regarding the potential benefits and harms associated with treatment options.
Shared Decision-Making
Process
Roles of Clinicians
Understand the information provided by patients and/or families (ask questions if he/she understands the information) and allow them to exchange their knowledge on other alternative treatment options that are not included in the information (e.g. herbal therapy, acupuncture etc.).
Ensure that they have fully understood the information and if necessary, provide decision counselling to support them in making decisions.
Elicit their values and preferences to each option (i.e. what is most important to them).
Mutual
Agreement
Recognize a
decision to be
made
Information
exchange
Clarification of
values and
preferences
Feasibility of
Options
Decision Support through: o Patient Decision Aids o Decision Coaching
Patient and/or Families Deliberation
Appendix F: Appropriateness of Care Toolkit - Tool #3
Appropriateness of Care Framework 72 Version 1: December 4, 2015
How to Embed SDM into Appropriateness of Care Projects?
SDM can be incorporated into any Appropriateness of Care projects as long as the
targeted clinical areas have more than one treatment option. The following tips can be
considered when embedding SDM into Appropriateness of Care projects:
When the Clinical Development Team maps a clinical flow or patient flow, it is
critical to:
Identifying decision points where PtDAs and SDM can be introduced to
patients; and
Identifying barriers and facilitators to implementing PtDAs.
Identify an appropriate PtDA from existing PtDAs25 or develop a new PtDA and
decision support tools (e.g. Ottawa Generic Decision support tool, SURE tool);
Create a system for PtDA distribution (e.g. who and how to provide PtDAs to
patients and/or families, how to ensure they received PtDAs, etc.)
Determine roles of each healthcare professional (e.g. physician, nurses,
physiotherapist, dietician etc.) and staff (e.g. administrative staff, case manager,
receptionist, etc.) in embedding SDM in clinical workflow
Identify progress and outcome measures for SDM and embed them into clinical
workflow
Embed the data as well as PtDAs and decision support tools in the electronic
medical record (EMR) to make it easier for clinician to incorporate SDM into
consultations with patients.
Potential Measures for Shared Decision Making
Patient Outcomes Indicators
For the patient outcomes, there is evidence that SDM increased patient knowledge of
treatment options, reduced their decisional conflict, and increased their satisfaction
with the treatment choices. The following measurement tools developed by the Ottawa
Hospital Research Institute (OHRI) can be used to measure quality of PtDAs, as well as
impacts of PtDAs on patients’ knowledge, decisional conflict, and confidence:
http://decisionaid.ohri.ca/eval.html.
25
Many high performing healthcare organizations around the world, including the National Health Services (NHS) in UK and Mayo Clinic in US, have developed patient decision aids (PtDAs) in various clinical conditions. In Canada, the Ottawa Hospital Research Institute website provides numerous existing PtDAs. Also, US non-profit organizations, such as Healthwise and the Informed Health Decision Making have developed various PtDAs and provide them to various healthcare organizations in US. Currently, patients in Saskatchewan can access various PtDAs through the Healthline Online developed by Healthwise: https://www.healthwise.net/saskhealthlineonline/Content/StdDocument.aspx?DOCHWID=share
Appendix F: Appropriateness of Care Toolkit - Tool #3
Appropriateness of Care Framework 73 Version 1: December 4, 2015
Patient Outcomes / Decision
Comfort (SURE tool) Indicators
Patients’ knowledge of treatment
choices
# of patients who reported that they understood
the benefits and risks of treatment options
Patient’s values
# of patients who reported that they were clear
about which benefits and risks matter most to
them
Support for patients to make a
decision
# of patients who reported that they had enough
support and advice to make a choice
Certainty of the decision # of patients who reported that they felt sure about
the choice they made for themselves
Total Score # of patients who scored 4/4 for these items
Patient Outcome: Satisfaction Indicators
Patient satisfaction with the
decision and/or decision making
process
# of patients who were satisfied with the decision
and/or decision making process
Decision regret # of patients who do not feel regret about the
decision made
Provider Outcomes Indicators
In terms of provider outcomes, research indicates that SDM improved the quality of
consultation without increasing the consultation time. The following indicators can be
used as SDM outcome measures:
Provider Outcomes Indicators
Quality of consultation
# of patients who indicated their clinician involved
them in SDM
# of consultations in which SDM was observed
Clinician and patient
consultation time
Amount of clinician and patient consultation time
spent for SDM compared to usual consultation
time
Clinician satisfaction # of clinicians reported that they are satisfied with
SDM
Appendix F: Appropriateness of Care Toolkit - Tool #3
Appropriateness of Care Framework 74 Version 1: December 4, 2015
References:
Coulter A, & Collins A. (2011). Making shared decision-making a reality: No decision about
me, without me. The King’s Fund.
Deyo RA, Cherkin DC, Weinstein J, Howe J, Ciol M and Mulley AG. Involving Patients
in Clinical Decisions: Impact of an Interactive Video Program on Use of Back Surgery. 2000.
Medical Care. 38(9): 959-969.
Mulley A, Timble C and Elwyn G. Patients’ Preferences Matter: Stop the Silent
Misdiagnosis. 2012. The King’s Fund.
Stacey D, Kryworuchko J, Murray AM, Mullan S and Légaré F. Decision Coaching to
Prepare Patients for Making Health Decisions: A Systematic Review of Decision Coaching in
Trials of Patient Decision Aids. 2012. Medical Decision Making. Vol 32(3): E22-32
Stacey D, Bennett LC, Barry JM, Col FN, Eden BK, Holmes-Rovner M, Llewellyn-
Thomas H, Lyddiatt A, Légaré F and Thomson R. Decision Aids for People facing Health
Treatment or Screening Decisions. Cochrane Database of Systematic Reviews. 2011. Issue
10.
75 Version 1: December 4, 2015
Appendix F: Appropriateness of Care Toolkit - Tool #4
Data Development and Measurements for Appropriateness of Care
Projects: Data Collection, Analysis and Reporting
Introduction
The purpose of this document is to highlight considerations when trying to identify and
access data to support Appropriateness of Care work.
The value of clinical data to drive quality improvement and change is well established:
“We can’t change what we don’t measure”. Timely tracking and review of patient
outcomes over time and visual display of the information can help identify: where
outcomes are being optimized and where they are not; where change in outcomes is a
result of random variation or true system change; and where and how processes can be
modified for positive impact.
Dr. Brent James (Intermountain Healthcare) provides an example of outpatient
management of anticoagulation and the importance of visually tracking patient
outcomes over time as illustrated in Figure 1 on page two.
Three clinicians in an outpatient clinic managed warfarin but none measured the impact
over time of changing the dosage on the desired outcome (INR). Patient LL had their INR
checked regularly and it was found to fluctuate. In response to the fluctuations and the
INR value falling out of the desired range, the physician would modify the dose. This
continued for some time with modifications to the medication dose occurring frequently
in response to each INR value. After many dosage alterations and INR fluctuations the
physician considered whether there was an appropriate dosage amount and how he could
know when to modify the dose to optimize his patient’s INR value (outcome). He graphed
his patient’s INR values over time and annotated his chart with the warfarin dose
changes. By graphing the data he could see the trends in the impact of the dosage changes
on the INR value and better understand when it was appropriate to change the dosage.
Experience has shown that clinicians are motivated by both generic data from the
literature and more localized data highlighting their own patients and practices.
Health data exists in a variety of datasets and formats in Saskatchewan. Section 2 of
this document outlines a few considerations when choosing to use existing data to
support Appropriateness of Care work. However, in many situations the clinical data
required to support clinical quality improvement is not available. In these cases new
datasets are needed. Section 3 of this document provides guidelines for measurement
system design and creating new datasets.
Appendix F: Appropriateness of Care Toolkit - Tool #4
76 Version 1: December 4, 2015
The steps in identifying and designing data correspond to the steps in the
Appropriateness of Care framework. Where appropriate these links are highlighted in
the document.
Figure 1
Intermountain Healthcare
Context Setting (pre-Project) Data
Identify, within the patient-centered clinical area of focus, preliminary data that
could provide some context:
Review key literature to identify relevant variables or metrics
Discuss key data with development team clinical lead
Consider where this data will be obtained
Provincial administrative databases. (See Appendix I for a list of databases
that the Health Quality Council has access to.)
o As of June 2015, eHealth Saskatchewan is currently creating a catalogue of
Saskatchewan datasets (See eHealth Saskatchewan for more information).
Health organization data (e.g. Saskatchewan Cancer Agency, Public Health
Observatory).
Clinical registries or project databases (e.g. Saskatchewan Spine Pathway).
Published Saskatchewan literature on the topic
Unpublished research with relevant data (e.g. medical student project).
Other published reports (e.g. CIHI reports)
Appendix F: Appropriateness of Care Toolkit - Tool #4
77 Version 1: December 4, 2015
Consider how the data will be analyzed and shared at the development team
meeting
How many years of data are important to share?
What stratifications and potential comparisons are needed (e.g. by health
region? by physician? by facility? etc.)
Are there particular sub-cohorts of patients of interest?
Within the database where this data is housed, what data codes should be
considered? (e.g. What specific ICD-10-CA codes would be needed from the
Discharge Abstract Database)?
How should the data be presented? (tables or graphs)?
Consider what types of privacy documents are needed in order to access,
analyze, and share this data, including data sharing schedules, ethics and patient
consent forms. Key contacts for information related to these are (this is not an
exhaustive list):
University of Saskatchewan Ethics (http://research.usask.ca/for-
researchers/ethics/)
University of Regina Ethics
(http://www.uregina.ca/research/REB/main.shtml)
Saskatoon Health Region Operational Approval;
(Shawna.weeks@saskatoonhealthregion.ca)
Regina Qu’Appelle Health Region Operational Approval; (http://www.rqhr-
rps.ca/research-ethics/)
Saskatoon Health Region Enterprise Risk Management (re: Data Sharing)
Project Data
Data to track effectiveness of changes
Within a project, clinicians may choose to trial a change in practice to improve patient
outcomes, better align with evidence based care or agreed upon standards, and reduce
variation. It is important to track the effectiveness of such change to understand how it
impacts outcomes and where further change may be needed. If there is variation in
how patients are treated within the practice, the impact of such variation on outcomes
need to be captured.
The following section outlines a process for identifying metrics to track effectiveness.
The detailed data that is often needed to highlight effectiveness and report outcomes
may not be available within existing Saskatchewan datasets. New data sets may need
to be developed.
Appendix F: Appropriateness of Care Toolkit - Tool #4
78 Version 1: December 4, 2015
Steps for identifying key metrics
Use developed process maps (a key step in helping the development team identify
projects within their clinical area of focus to work on) to identify key outcome, process,
and input metrics that need to be captured
Outcome Metrics: Clinical outcome information provides a means to evaluate the
effectiveness of the treatments in achieving their stated goals. Correspond
directly to the outcomes tracked in a randomized control trial. Outcomes fall
into three categories:
Physical outcomes: Correspond to the traditional ideas of quality and equate to
‘medical outcomes’
Service (satisfaction) outcomes: Parallel to health care access and track
consumers’ subjective perceptions of the interaction between a provider and a
consumer.
Cost outcomes: The resources that a process consumes as it operates.
Process Metrics: Measurable factors that track a process’ important outputs
include:
Process Metrics: Represent critical performance steps that are essential to the
process’ successful operation. Correspond directly to the protocols that
control treatments in a randomized control trial.
Input Metrics: Describe a process’ appropriate domain of application.
Correspond directly to the eligibility criteria in a randomized control trial.
1) Consider what metrics related to medical outcomes, patient experience and cost
are useful to understand what happened to the patient as they went through the
process.
2) Consider what areas within the process are important to capture. Focus on key
areas where decisions are made and where it may be useful to understand what
decision was made and why. Consider areas of variation in practice. Will it be
useful to track the details of the step in order to understand differences in
practice that may exist (e.g. between physicians) to understand the impact that
the various decisions have on the patient outcomes?
3) Consider what characteristics of the patient are important to know. What patient
demographics, co-morbidities, or medical and surgical history is important to
know as it drives treatment decision making and may impact patient outcomes?
Appendix F: Appropriateness of Care Toolkit - Tool #4
79 Version 1: December 4, 2015
Consider the role of the patient voice in identifying measures
Patient Reported Outcome Measures (PROMs) capture the patient perspectives on
quality of life. PROMs are an umbrella term covering a range of survey tools used to
obtain reports by patients on their health status, without interpretation by a clinician.
Typically PROMs surveys are issued before, and at specific intervals following a health
related procedure. Information gathered from the surveys may be indicative of
whether or not healthcare interventions or services make a difference to patients’ health
and quality of life, from their point of view. PROMs information is typically collected via
self-administered questionnaires on paper or computer, or in-person or telephone
interviews, asking patients about symptoms, functionality, and various other aspects of
physical, mental, and social health relevant to their quality of life.
Evidence shows that routine use of PROMs has the potential to influence health care.
Not only can PROMs help patients and clinicians make better decisions, but can also
enable comparisons of providers’ performances to stimulate improvements in services
and provide information to support evaluation of the efficacy, effectiveness and cost-
effectiveness of health care treatments.
PROMs questionnaires may be generic or disease/condition specific. A general and
widely accepted recommendation by experts is that generic and disease specific PROMs
provide complimentary information.
Generic PROMS are designed to be used in any disease population. The EuroQol EQ-
5D, SF Health Survey series and Health Utilities Index (HUI) are the most commonly
used generic PROMs surveys. Generic survey tools enable comparisons to be made
across different diseases and produce utility scores that can be used to calculate quality
of life adjusted years (QALYS) for cost-effectiveness analysis.
Disease or condition-specific PROMs measure outcomes that are of importance for
patients with a particular medical condition. They are more sensitive in detecting
change over time and differences between groups of patients with the same condition.
Condition-specific surveys provide more detailed information that is relevant to the
practice of clinicians. An example of a disease specific survey tool currently used in
Saskatchewan is the Western Ontario and McMaster Universities Osteoarthritis Index
(WOMAC) used to assess pain, stiffness, and physical function in patients with hip
and/or knee osteoarthritis. For more information on common PROMS tools:
EQ5D (http://www.euroqol.org/)
SF-36 (http://www.rand.org/health/surveys_tools/mos/mos_core_36item.html)
Appendix F: Appropriateness of Care Toolkit - Tool #4
80 Version 1: December 4, 2015
Consider how evaluation of Shared Decision-Making (SDM) and patient experience
surveys can be utilized to capture the patient perspective of their journey.
SDM measures (See the Tool #3: Shared Decision-Making: Patient Involvement in
Treatment Decisions)
Patient Experience Surveys
Consider metrics will be reported back to the group and how it will be used
How will key metrics be presented (as proportions, raw numbers, etc.).
How should the metrics be stratified? (Are there important patient characteristics
that the metrics should be stratified by?)
How often should the metrics be updated and shared? (Monthly, quarterly)?
Who should the reports be shared with?
Consider what data will be needed to report these metrics
Identify the data needed to report each metrics. Consider whether the data
needed are available in existing datasets (consider data sources outlined in
section 2b). Experience with other similar projects (e.g. VAWG) highlighted a
lack of clinically detailed data within the existing Saskatchewan data sources.
The data needed to track patient outcomes and processes may not be available
and new data may be needed.
Consider capturing new data and creating new databases to report the key
metrics.
If creating new data, consider how new data should be collected
Identify where in the workflow the data needed is generated. Add detail to the
process map about where in the patient process key the information (the data) is
captured.
Consider how that information could be collected at the point-of-care. The
most sustainable way to collect accurate data is to integrate the data collection
process into workflow, collected by someone at point-of-care. Most often, the
data needed to generate the metrics is information that is already collected by a
clinician throughout the course of treating a patient. Use data for patient
(disease management) but also for rolling up for reporting and accountability at
the level of individual health professionals, facilities/clinics/practice groups,
hospitals, regions and at the provincial and national level. It is important that
the right data is collected once, at the point of origin and then used for all
applications.
For example, a physician may collect patient’s medical history and co-
morbidities in a consult note. This is information that is also needed for key
Appendix F: Appropriateness of Care Toolkit - Tool #4
81 Version 1: December 4, 2015
metrics for this project. Consider standardizing the consult note so that it can
still be used by the individual physician to treat the patient, but can also be used
for data collection (e.g. modify an open-ended consult note to include
standardized check boxes).
Observe the clinical process, the patient flow, and flow of information. It is
valuable to see the process as it happens. Often you may see that the process in
reality is different from the process that was described when mapped. Seeing the
process in person can help understand where best the information can be
captured, integrated into the workflow and transmitted.
Don’t hesitate to start with paper-based data collection. It is likely that new
forms will undergo multiple iterations before a final version that satisfies both
clinical needs and data collection needs, and it is much easier to modify paper
versions.
It is important to avoid recreational data collection and asking people to collect
data that is not needed. Do not collect data that is not needed for metrics, just for
the sake of collecting data.
Consider how data will be analyzed and reported
If able to use existing data consider how often the dataset will be extracted from
its data source (monthly, quarterly, and semi-annually). Consider who and how
it will be analyzed and how it will be shared with the project team (frequency,
formatting, etc.).
If creating new databases consider how the data will flow from the point-of-care
to source that can enter it into a database and analyze it. Options include faxing
paper documents, or using a secure file-transfer program (FTP). An FTP is an
online program that allows multiple users to access a shared account to upload
and download files.
Similar to using existing data, consider how the new data will be analyzed,
reported and shared. Will metrics be reported as graphs or tables? How often
will they be shared? Who will the metrics be shared with?
Consider types of privacy documents are needed in order to access, analyze, and
share this data.
Consider transitioning to an electronic system
If new data collection is paper-based consider transitioning it to an electronic
system over time. As the project is replicated and spread it may become
unsustainable to continue with a paper-based version. Movement to an
Appendix F: Appropriateness of Care Toolkit - Tool #4
82 Version 1: December 4, 2015
electronic platform may facilitate ease of data collection, data entry, analysis and
reporting.
83 Version 1: December 4, 2015
Appendix F: Appropriateness of Care Toolkit - Tool #5
Saskatchewan Administrative Databases
The following are datasets that can be accessed from the Health Quality Council (HQC).
If an interested party requests access to HQC datasets they must follow the HQC
requirements for using HQC data. For more information contact Tracey Sherin,
Director, Analysis and research Partnerships, tsherin@hqc.sk.ca.
Dataset Key Variables in Dataset
Person Health Registration
System (PHRS)
Health Services Number (encrypted)
Person year of birth
Sex
Marital status
Registered Indian status
Dates of coverage – initiation and termination
Reason for termination
Status of health insurance coverage
Regional Health Authority where person resides
Current recipients of social assistance
Hospital Discharge Abstract
Database (DAD)
Health Services Number (encrypted)
Year and month of birth
Sex
Residence
Date of admission
Date of discharge
Discharge diagnosis (ICD-9 or ICD-10, all fields)
Procedure codes (CCP or CCI, all fields)
Accident code
Case-mix group
Resource intensity weight
Mortality in hospital flag
Hospital identification number
Hospital category
Institutional Supportive
Care System Dataset
Health Services Number (encrypted)
Type of admission
Date of admission
Date of discharge
Reason for discharge
Regional Health Authority where resident resides
Physician Services Claims
File: Medical Services
Branch (MSB)
Health Services Number (encrypted)
Residence
Provider MSB number (encrypted)
Physician specialty
Referring physician
84 Version 1: December 4, 2015
Dataset Key Variables in Dataset
Fee code approved
Diagnostic code (ICD or MSB) associated with service
Service code
Date of service
Number of services
Type of service or major group code
Location of service code
Payment information
Saskatchewan Resident
Geography
Health Services Number (encrypted)
Urban or rural area of residence (based on estimated
driving time from the centroid of person’s residential
postal code to centre of closest city with population >
15,000)
Income quintile
Regional Health Authority where person resides
Resident Assessment Index
Minimum Data Set (RAI-
MDS)
Identification Information Health Services Number (encrypted)
Unique registration identification
Assessment reference date
Treaty/band
Marital status
Facility number
Province/territory of issue
Responsibility for payment
Reason for assessment
Responsibility/legal guardian
Advanced directives
Demographic Information
Admission Date
Admitted from/level of care (at entry)
Lived along (prior to entry)
Residential history (5 years prior to entry)
Education (highest completed)
Language
Mental health history
Conditions related to developmental disability status
Cognitive Patterns Comatose
Memory
Memory/Recall ability
Cognitive skills for daily decision making
Indicators of delirium periodic disordered
thinking/awareness
85 Version 1: December 4, 2015
Dataset Key Variables in Dataset
Change in cognitive status
Communication/Hearing Patterns Hearing
Communication devices/techniques
Modes of expression
Making self-understood
Speech clarity
Ability to understand others
Change in Communication/hearing
Vision Patterns Vision
Visual limitations/difficulties
Visual appliances
Mood and Behaviour Patterns Indicators of depression, anxiety, sad mood
Mood persistence
Change in mood
Behavioural symptoms
Change in behavioural symptoms
Psychosocial Well-Being
Sense of initiative/involvement
Unsettled relationships
Past roles
Physical Functioning and Structural Problems
Bed mobility
Transfer
Mobility
Dressing
Eating
Toilet use
Personal hygiene
Bathing
Test for Balance
Functional limitation in range of motion
Modes of locomotion
Modes of transfer
Task segmentation
ADL functional/rehab potential
Change in ADL function
Continence in Last 14 Days Bowel continence
Bladder continence
86 Version 1: December 4, 2015
Dataset Key Variables in Dataset
Bowel elimination pattern
Appliances and programs
Change in urinary continence
Disease diagnoses Disease and infection diagnoses
Health Conditions Problem conditions
Pain symptoms
Pain site
Accidents
Stability of conditions
Oral/nutritional status
Oral problems
Height and weight
Weight change
Nutritional problems
Nutritional approaches
Parenteral or enteral intake
Oral/Dental Status
Oral status and disease prevention
Skin Condition Ulcers
Type of Ulcer
History of resolved ulcers
Other skin problems or lesions present
Skin treatments
Foot problems and care
Activity Pursuit Patterns
Time awake
Average time involved in activities
Preferred activity settings
General activity preferences
Prefers change in daily routine
Medications Number of medications
New medications
Injections
Days received the following medication
Special Treatments and Procedures Special treatments, procedures and programs
Intervention programs for mood, behaviour, cognitive
loss
87 Version 1: December 4, 2015
Dataset Key Variables in Dataset
Devices and restraints
Hospital stay(s)
Emergency room(er) visit(s) in last 90 days
Physician visits in the facility the last 14 days or since
admission
Physician orders
Abnormal lab values
Discharge Potential and Overall Status Discharge potential
Overall change in care needs
Assessment information Participation in assessment
Vital Statistics Health Services Number (encrypted)
Date of death
Cause of death
Prescription Drug Plan
ALLDIN file
Drug information
Pharmacologic-therapeutic class of drug
Drug identification number (DIN)
Drug active ingredient number
Generic and brand names
Strength and dosage form
Date dispensed
Quantity dispensed
Provided information
Prescribed identification number
Dispensing pharmacy number
Cost information
Unit cost of drug materials
Dispensing fee and mark-up
Consumer share of total cost
Government share of total cost
Total cost
Prescription Drug Plan
Historical Claims
Health Services Number (encrypted)
Drug identification number (DIN)
Date of dispensing
Quantity of drug dispensed
Drug type (EDS, MSD)
Drug class (Major, minor)
Home Care Dataset Health Services Number (encrypted)
Date of admission
Date of discharge
Type of admission
Reason for discharge
88 Version 1: December 4, 2015
Dataset Key Variables in Dataset
Discharge arrangements
Discharge from hospital prior to initiation of home
care
Living arrangements before admission
Type of residence before admission
Senior housing
Regional health authority
Out of province flag
Resident Assessment Index
Home Care Dataset (RAI-
HC)
Identification Information
Health Services Number (encrypted)
Province/territory issuing health care number
Demographic Information Sex
Aboriginal identity
Marital status
Language
Education (highest complete)
Responsibility / advanced directives
Responsibility for payment
Referral items
Data case opened / reopened
Reason for referral
Understanding goals of care
Time since last hospital stay
Where lived at time of referral
Who lived with at referral
Prior residential care facility placement
Assessment Information Assessment reference date
Reason for assessment
Location of Assessment Location of assessment
Facility admission date
Cognitive patterns
Memory recall ability
Cognitive skills for daily decision making
Indicators of delirium
Communication/Hearing Patterns
Hearing
Making self-understood
Ability to understand others
Communication decline
Vision Patterns
89 Version 1: December 4, 2015
Dataset Key Variables in Dataset
Vision
Visual limitations/difficulties
Visual decline
Mood and Behaviour Patterns Indicators of depression, anxiety, sad mood
Mood decline
Behavioural symptoms
Change in behavioural symptoms
Social Functioning Involvement
Change in social activities
Isolation
Informal Support Services
Two key informal helpers (primary and secondary)_
Caregiver status
Extend of informal help (hours of care, rounded)
Physical Functioning IADL
o Meal preparation
o Ordinary housework
o Managing finances
o Managing medication
o Phone use
o Shopping
o Transportation
ADL
o Mobility in bed
o Transfer
o Locomotion in home
o Locomotion outside of home
o Dressing upper body
o Dressing lower body
o Eating
o Toilet use
o Personal hygiene
o Bathing
ADL decline
Primary modes of locomotion
Stair climbing
Stamina
Functional potential
Continence in Last 7 Days Bladder continence
90 Version 1: December 4, 2015
Dataset Key Variables in Dataset
Bladder devices
Bowel continence
Disease diagnoses Disease and infection diagnoses
Health problems and preventive health
measures Preventive health services (past 2 years)
Problem conditions present on 2 or more days
Pain
Falls frequency
Danger of fall
Lifestyle (drinking/smoking)
Health status indicators
Other status indicators
Nutrition/hydration status
Weight
Consumption
Swallowing
Oral/Dental Status
Oral status and disease prevention
Skin Condition Skin problems
Ulcers (pressure/stasis)
Other skin problems requiring treatment
Prior pressure ulcer
Wound/ulcer care
Environmental assessment Home environment
Living arrangement
Service utilization Formal care (minutes rounded to even 10 minutes)
Special treatments therapies, programs
Management of equipment (in last 3 days)
Visits in last 90 days of since last assessment
Treatment goals
Overall change in care needs
Trade offs
Medications Number of medications
Receipt of psychotropic medication
Medical oversight
Compliance/adherence with medications
List of all medications
91 Version 1: December 4, 2015
Dataset Key Variables in Dataset
Assessment information
Participation in assessment
Physician Characteristics Medical Services Provider number (encrypted)
Flag indicating general practitioner versus specialist
Specialty
92 Version 1: December 4, 2015
Appendix F: Appropriateness of Care Toolkit - Tool #6
Important Documents Regarding Data
1. Data Sharing Schedule.
A Data Sharing Schedule is a legal document between the data owner and the party
wishing to use data for a certain purpose. It outlines the terms of agreement for use of
the data (data specifics, security, reporting conditions, etc.).
2. Patient Consent
If the project requires creating new databases and collecting new data, patient consent
may be required. In most cases, because the data required is standard clinical
information collected to treat the patient, consent is needed, not to collect the patient
information, but rather to have the information used in another way (e.g. research,
quality improvement). An example of a patient consent letter is provided on the
following page.
Appendix F: Appropriateness of Care Toolkit - Tool #6
93 Version 1: December 4, 2015
Dear Patient;
As described in the attached brochure, your surgeon is partnering with the Health Quality Council (HQC) of
Saskatchewan, a quality improvement organization that works closely with the health system, to better understand and
improve the care available to patients in Saskatchewan. The vascular surgeon you are about to see is seeking to collect
information on the course of your care. This is routine medical information that your surgeon already collects to assist
with your care. Your surgeon has authorized specific personnel at the HQC to provide reports about the health services
they provide and with your consent, your medical information will be shared, via secure transfer, with those specific
personnel from the HQC. Your information will be shared and used in accordance with the requirements of the Health
Information Protection Act.
In addition to your demographic information, diagnosis, medical history and the dates and types of service provided to you, the surgeons would like to collect the following information:
EQ5D Survey – A quality of life survey to tell the surgeon about how your condition affects your daily life Patient Satisfaction Survey- For you to tell the surgeon about your experience with receiving care
Right now, you are asked to complete the EQ5D survey. You will be contacted on two occasions by phone and/or email
by the personnel from the HQC that have been authorized to access your information, initially three months and then
one year after the treatment you receive. In order to follow-up with you, the designated personnel from the HQC will
require your contact information (name and phone number or email). The person (s) from the HQC who contacts you is
authorized for this role by your surgeon and will be specifically trained to maintain your confidentiality. This survey
information will help your surgeon follow up on your recovery as well as enable evaluation of the vascular surgical
services available in Saskatchewan.
All information collected about you and your medical condition will be stored in your surgeon’s office like the rest of
your medical record. Additionally, information provided to HQC will be stored in a secure manner at the HQC. Only your
surgeon, their office staff, and those specific individuals from the HQC will be allowed to access any information that
directly identifies you. As part of the evaluation of vascular surgical services, the information collected from you may be
linked to other health information about you (for example, prescription medications used; hospitalizations) that are
collected by the Ministry of Health. This data linkage is done in a manner that protects your privacy by ensuring the
information remains de-identified to all except your surgeon and his/her authorized health information service
providers.
The information you provide will be kept secure and confidential. Your participation is voluntary. If you decline to
participate your care will not be compromised in any way. You may withdraw your consent at any time. However, this
withdrawal is not retroactive. If you have any questions please call the number on the brochure, or speak to your
surgeon about why this project is important to them.
I understand the information in this letter, and give my consent to the collection and use of information about me for the purposes of monitoring, evaluating and improving care provided by vascular surgeons. I prefer follow-up contact to be by: Phone; Phone #: _____________________________ Email; Email Address: ____________
Name: (please print) _______________________________________
Signature: Date (yyyy-mm-dd):
94 Version 1: December 4, 2015
Appendix F: Appropriateness of Care Toolkit - Tool #7
Surgical Variation and Appropriateness Working Group (Vascular
Working Group)
1. Use of administrative data to identify problem
In 2012, the Saskatchewan Discharge Abstract Database (administrative database) was
queried and age-standardized rates of 30 high volume surgical procedures were reported.
The rates were stratified based on patient’s health region of residence, not where the
procedure occurred. A committee of health system administrators, policy consultants, and
physician leaders reviewed the report and noted substantial variation in rates of procedure
between health regions for some procedures. A Variation and Appropriateness Working
Group (VAWG) Physician Group was developed for four clinical areas with variation.
One of these groups included vascular surgeons from Saskatoon Health Region and
Regina Qu’Appelle Health Region to explore perceived variation between rates of infra-
inguinal bypass surgery.
2. Use of administrative data to further understand issue
To understand the root cause of the variation further queries were attempted with
administrative databases to get more clinically detailed data. It was identified that the
clinically detailed data needed was not available within existing data sets.
3. Processed map to identify key issues and metrics
The vascular surgeons recognized the importance of having this data to better understand
patient outcomes and variation in patient populations and treatment process and
supported the idea of developing a new data set. The group convened in March 2013 for a
full day session. The patient process was mapped (from initial visit with the vascular
surgeon through to the decision for medical treatment to follow-up). Variation in
physician practice was noted on the process map as a key area to track.
After mapping the process they identified key outcome, process, and input metrics that
would be important to capture to further understand patient outcomes. Examples of the
key metrics identified include:
Outcome Metrics: % of patients that experience a complication following an invasive
treatment
Process Metrics: By type, the % of patients that receive diagnostic imaging following
a consult.
Input Metrics: % of patients seen by a vascular surgeon for consult, by Rutherford
classification (disease severity)
Appendix F: Appropriateness of Care Toolkit - Tool #7
95 Version 1: December 4, 2015
5. Considered the data needed to report metrics
The data needed to report each metric was identified. For example, for the process metric,
% of patients that receive diagnosis imaging following a consult the numerator and the
denominator for the calculation were identified.
6. Considered how data will be collected
All of the data required to report these metrics is information that is routinely collected
throughout the course of providing care to the patient. It is the information that a
physician needs to make treatment decisions (with the exception of Patient Reported
Outcomes). Four key areas where physicians collect patient information were identified,
and new information sheets that were organized in a standard way to collect data were
created. These included:
1. Patient information sheet collected after the initial patient consult with the surgeon.
This information sheet captures key patient comorbidities, medical history and next
steps regarding treatment.
2. Procedure sheet that captures information about the patient’s treatment.
3. Discharge sheet that captures information about the patient’s post-procedure
experience.
4. Follow-up information sheet that captures information about the patient’s post-
hospital experience and follow-up.
Additionally, a PROMs information sheet was implemented to capture patient’s
completed pre-treatment and post-treatment (3 months and 1 year) which reflects the
patient’s perspective of quality of life.
7. Consider how data will be transferred
A paper based data collection began with using the information sheets in the physician’s
offices and in the hospital. A flow process for the papers to move from the hospital, to the
physician’s office for collation, to the Health Quality Council for data entry and analysis
was developed. This process involved hospital and office staff.
8. Considered how metrics would be reported back
Individual physician reports were developed to share with each vascular surgeon within
the project team. The reports provided their individual data, Saskatoon Health Region
and Regina Qu’Appelle Health Region data, and provincial data. These reports included
tables and graphs to report the key metrics.
Appendix F: Appropriateness of Care Toolkit - Tool #7
96 Version 1: December 4, 2015
9. Transition to electronic data system
After 12 months using the paper based patient information forms to collect data,
conversations with eHealth Saskatchewan were initiated to consider transitioning to an
electronic system, which better integrates data collection into the physician’s workflow.